Arrowe Park Hospital emergency department needs improvement

It follows an unannounced visit by inspectors from the health and social care regulator in March, following concerns about access to the emergency department.

According to the report, ratings for 'how effective', 'caring', and 'well-led' remain rated as 'good' but the overall ratings for the hospital and trust are unchanged with both remaining 'requires improvement'.

Karen Knapton, the CQC's deputy director of operations, said: "During our inspection we found staff were doing their best in a busy, high pressure environment with significant safety risks because of overcrowding.

"Staff told us overcrowding meant they weren’t functioning as an effective emergency department and people were being cared for in areas not designated for care and treatment. Leaders were also struggling to mitigate the risks of staff shortages due to a high rate of sickness absence.

"Leaders had a plan to safely manage the number of people in the emergency department, but we found this wasn’t always being followed".

On both visits, inspectors found people were being treated in corridors in the emergency department as well as in the main hospital corridor.

Arrowe Park Hospital's front entrance (Image: courtesy of Wirral University Teaching Hospital Trust) The ambulance arrival zone was also being used for additional beds due to 'challenges of patient flow through into the main hospital'.

Staff told inspectors that many people in the department were waiting for a medical review, or to be transferred to a hospital ward, rather than emergency care.

Staffing issues were also described as having 'a knock-on effect on other healthcare partners with local ambulance trust staff saying they often had to wait and monitor patients they dropped off at Arrowe Park.

The report said: "This was preventing some ambulance crews from responding to other emergency calls.

“Despite these challenges, people in the emergency department gave mostly positive feedback about staff.

"When we spoke to people who were receiving treatment in corridors they hadn’t all been told how long they would be in the corridor, but they knew whether they were waiting to be moved to another hospital bed or if they were going to be discharged. We also saw staff using accessible language tools to communicate with people.

“The trust is aware of where improvements are needed and has already started to address the issues we found at this inspection.

"We will continue to monitor the trust, including through future inspections, to ensure the necessary improvements are made so people can receive safe and appropriate care."

During the visit, inspectors found:

• Building work at the time of inspection meant the waiting room wasn’t visible to the reception area. Inspectors witnessed a period where no staff checked on people in the waiting room or carried out any observations. Security staff who were frequently in the waiting room said they were able to seek clinical staff assistance if they noted anything of concern, but they are not trained clinicians so may not be aware of someone’s condition deteriorating.
• Staff reported low morale due to a stressful working environment. The trust had plans in place to increase staff numbers and was working to reduce staff sickness and absence.
• Leaders monitored how the service performed, however not all audits, to ensure safe care and treatment, which had been suspended during the pandemic had been re-instated.
• Incidents were managed safely, and leaders held regular meetings to discuss incidents. However, not all staff received feedback when incidents were reported and some shared concerns that action had not always been taken.
• The overcrowding meant people’s dignity and privacy was being compromised. We saw staff taking bloods from someone in the middle of a waiting room and privacy screens weren’t always used around people who were on trolleys in the corridors. In addition, confidential conversations between staff and people receiving treatment, as well as staff handovers, sometimes occurred where other people could overhear.

However

• Senior leaders were visible within the service and helped as needed. Staff felt they could talk with the new leadership team and that they were approachable for both staff and people using the service.
• The trust had worked closely with their local mental health trust to develop a side-by-side assessment process for people who came to the emergency department with mental health needs.
• The service had several projects underway with the local integrated care board to improve hospital flow, treatment pathways, service escalation, and discharging people.

The report will be published on CQC’s website on the hospital page in the coming days.

In response to the report's findings, Dr Nikki Stevenson, deputy chief executive and executive medical director at Wirral University Teaching Hospital, which runs Arrowe Park, thanked the CQC for its inspection, adding the trust was working to 'continually improve our emergency care services'.

Arrowe Park Hospital's front entrance (Image: courtesy of Wirral University Teaching Hospital Trust) She said: "They have acknowledged that we have already begun addressing issues identified. They also referenced building work which causes short term challenges during the construction a multi-million pound Urgent and Emergency Care Facility being built while the Emergency Department remains open. It will offer a greatly improved experience for patients.

“To be rated as ‘Good’ in three out of five domains is extremely positive. This includes a ‘Good’ rating for being Effective, Caring and Well-led and this is a testament to the continued hard work of our staff and the care they give to patients.'

In the CQC's urgent and emergency care patient survey results, the trust scored ‘better’ than the majority of NHS Trusts for support and care for patients after leaving A&E.

It scored ‘better’ than other Trusts for how well patients were kept informed about their wait and what would happen next, involvement in decisions around their care and staff discussing with patients whether they needed health or social care services after leaving A&E.

Dr Stevenson continued: “As with other Trusts, the emergency department faces very high levels of attendances. Unplanned care across the wider healthcare system created a real pressure point in the emergency department when the inspection was carried out in March, resulting in CQC inspectors requiring more assurance around the Safe and Responsive domains which remained as 'requires improvement’.

Dr Stevenson described the practice of providing care to patients in the corridor of the hospital as 'an issue of national significance not isolated to our department and the result of a number of factors including the trust's commitment to release ambulance crews back into the community to attend to those in need, unplanned care demand and bed occupancy."

Dr Stevenson said the trust was working with local partners, NHS England and the Advancing Quality Alliance to improve pathways for patients into the department to mitigate against the concerns that accompany care being provided within corridors.

“As part of our winter planning we are creating additional bed capacity which will help to reduce corridor care.

"Going forward, our integration plans with Wirral Community Health and Care Trust will improve and streamline care to the residents of Wirral, including those requiring urgent and emergency care.

"We remain committed to providing the best care to the communities we serve."