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A hospital trust has been ordered to improve staffing arrangements at its emergency department in Norwich and ensure that nurse shortages do not cause delays in triage, following concerns raised over patient safety.
The warning comes from the Care Quality Commission (CQC) after an inspection which rated Norfolk and Norwich University Hospital’s emergency department as “requires improvement”.
“Nursing leads told us they were often four or five qualified nursing staff short on each shift”
Inspectors had visited the department in December after performance data flagged that national targets for waiting times were not being met, meaning patient safety could be at risk.
During the inspection, the CQC witnessed this in action and saw that walk-in patients were not always triaged within 15 minutes of arrival, which is the national standard.
In addition, it found there was no clear system to escalate patients from the triage queue if their condition worsened.
A key cause of concern for the health watchdog was that the service did not have enough nursing staff with the right qualifications, skills, training and experience.
At the time of inspection, the CQC said the number of registered nurses on the early shift at the department was “five less than planned” and that there were “four less than scheduled on the late shift”.
“Nursing leads told us they were often four or five qualified nursing staff short on each shift,” the CQC said in its report published today.
However, the regulator said shortfalls were “discussed and mitigated at safer staffing meetings”.
On the day of inspection, for example, emergency department clinical educators had been brought in to provide extra clinical support.
The impact of the coronavirus pandemic on nurse staffing levels was also flagged within the report.
“On inspection a senior ED staff member told us their department was currently working with a 6% extra loss of nursing staff due to Covid-19 related factors,” noted the CQC.
Nurse sickness and Covid-19 related absence was the focus of a recent Nursing Times survey which revealed almost all nurses were working shifts that had been short-staffed due to colleagues being unwell or isolating.
Meanwhile, there were also concerns raised in the CQC report regarding infection prevention and control measures.
Inspectors warned that staff did “not always use equipment and control measures to protect patients, themselves and others from infection”.
For example, there were instances where staff did not wash their hands between patients.
There were also examples of staff not following the trust’s own guidance around personal protective equipment in regards to wearing face shields and goggles, which was updated in November 2020.
The CQC said it saw five triage nursing staff who were not wearing any eye protection within two metres of patients, which was not in line with the trust’s policy.
Following the inspection, the CQC used enforcement powers at the Norfolk and Norwich University Hospitals NHS Foundation Trust and rated the emergency department as “requires improvement” overall.
It served the trust with a section 29A warning notice, which means that it must address the issues outlined in the report to avoid more significant action.
As part of this, the department must improve triage to better respond to patients at risk of deterioration and continue to take action to mitigate the risks of failing to meet key national targets.
In addition, the trust has been ordered to ensure that nurse shortages do not cause delays in triage.
“The trust must improve the department’s staffing arrangements and triage processes”
Fiona Allinson, CQC head of hospital inspection, recognised that at the time of the visit the department had been “under significant pressure due to the challenges caused by Covid-19”.
However, she said the health watchdog had a “duty” to inspect the trust following performance concerns.
“The trust must improve the department’s staffing arrangements and triage processes, so that it assesses and treats patients promptly and ensures their safety,” she said.
“It must also ensure that equipment is checked for safety, and that guidelines to prevent the spread of infection are followed.”
Ms Allinson said that following the inspection, trust leaders “know what must be done to ensure that people are assessed and treated within the timeframes they should be able to expect”.
The CQC will “continue to monitor the department closely to ensure that patients receive safe and effective care and treatment”, she added.
Within the report there were also examples of “outstanding practice” which the CQC recognised.
These included the employment of safety nurses whose role was to assess patients in ambulances, when the department was too busy to assess people brought by ambulance inside.
However, as part of the improvements listed by inspectors, the CQC stressed that action must be taken to ensure theses nurses could fulfil their role properly, following concerns that in some cases nurse staffing gaps meant the department could not always have an allocated safety nurse.
Overall, inspectors said they found an improved culture within the department compared to its previous inspection and recognised that staff were motivated and sought to work as a team to address patient need.
The department had previously been rated “requires improvement” following a comprehensive inspection of the trust which concluded in January 2020.
The trust remains rated “requires improvement” overall.
In response to today’s report, Sam Higginson, the trust’s chief executive, said it had taken “immediate action in response to the CQC’s concerns”.
The department now had “dedicated staff supporting patient triage available 24/7, we have increased our nursing numbers, and have eight new consultants joining us soon to help bolster the improved culture and stable leadership acknowledged by the CQC”, he added.
“Our staff have gone above and beyond during the pandemic and that is reflected in the recognition of outstanding practice in our older people’s emergency department and safety nurses, and we are determined to continue to improve our performance, together, to deliver the best possible care and patient experience,” he said.