Some progress made at Ysbyty Glan Clwyd emergency department but concerns remain

A north Wales emergency department which had been accused of “continuing to fail patients” has been de-escalated as a Service Requiring Significant Improvement (SRSI).

A recent Healthcare Inspectorate Wales (HIW) visit to Ysbyty Glan Clwyd found that improvements had been made following the release of a damning report released two years ago.

The hospital’s emergency department was designated a Service Requiring Significant Improvement (SRSI) in May 2022 after an inspection found multiple areas of concern relating to patient safety and evidence of poor management of health and safety risks.

Healthcare Inspectorate Wales’ SRSI process aims to identify service failures, to drive forward urgent improvement.

A follow-up inspection then took place in November 2022, which noted only minimal improvement, leading to the designation remaining in place.

HIW findings

In a report released today HIW have confirmed that following a three-day inspection in April and May of this year, enough progress has been made to de-escalate the emergency department at Ysbyty Glan Clwyd as a SRSI.

It found a “marked improvement within the areas of significant concern identified in 2022.”

This included the timely escalation of patients with critical and high-risk conditions, and strengthened oversight of the waiting area compared to previous inspections.

Overall, HIW inspectors found an improved culture, an increasing in staffing levels and stronger leadership.

During the inspection HIW said it that the department’s waiting room “had improved with patient emergencies escalated and well managed.”

It also noted that overall, the department was clean and tidy, with robust infection prevention and control measures in place; and general health and safety risks assessed.

Since the previous inspection, the completion rates for mandatory staff training had improved; and there was good visible leadership within the department.

HIW noted that “it was encouraging to see staffing levels had also improved, and there was less reliance on agency staff.”

There was also patient praise for the staff in the department, with 12/25 describing the service they had received as “very good”, while 11/25 said it had been “good”.

The inspectorate also found that risks to health and safety within the emergency were being managed appropriately – a significant improvement on the previous inspection in 2022.

Inspectors also  evidence of strong staff communication during shift handovers, and good working relationships within the department and with ambulance staff.

HIW also said it witnessed positive staff to patient interactions, with staff treating patients with dignity and respect, despite challenging conditions

Need for further improvements

Despite the de-escalation, HIW say that several issues remain for the service – which continues to operate in “highly demanding and challenging conditions.”

This includes excessive waiting times, issues with medication management and insufficient checks of life-saving equipment.

One of the main issued raised was the pressure and demand within the emergency department and the increased risk this could have to patients.

During the inspection there were around 50 patients each day who were deemed well-enough to be discharged with the unit at full bed capacity, say HIW.

Delays were primarily caused by patient waits for further rehabilitation, a care package to be put in place or a placement in another care facility.

During the three day inspection patients were waiting roughly four hours for treatment within the department, with just under a quarter of patients waiting over twelve hours before being seen.

Inspectors found that one patient was not seen by a doctor for over 10 hours with a suspected neck of femur fracture, and no record of pain relief.

Some patients also told HIW they had waited up to 48 hours and had not been informed or updated on their care and treatment plans.

During the inspection HIW “required immediate assurance that action would be taken in several areas including the checking of lifesaving equipment, the management of medications, and the procedures in place to conduct regular patient check-ups, assessments, and observations.”

It found that whilst medication management processes were “generally safe and in line with national standards and the health board’s policies” there were still risks to patients.

According to the report the inspectors found that a patient being administered an intravenous infusion in a quantity that was not prescribed and there was no fluid balance chart or cannula care plan in place for the patient.

They also found that fluid balance charts and cannula care plans were not in place for other patients whose care records we viewed

HIW said: “Inspectors were not assured that medication management processes were sufficiently robust and safe due to inaccuracies with administering medication, and the inadequate monitoring of patient conditions such as fluid intake for issuing cannulas.

“It was concerning to note that some patients, who needed either pressure area risk assessments, or falls risks assessments, didn’t receive these assessments until they had been in the department for over six hours.

“Consequently, adjustments were not immediately in place for those at risk due to mobility issues, or increased fragility.

“There were often delays in patients receiving treatment from specialist doctors, an area identified for improvement in the unit’s previous inspection.

“It was also concerning to find resuscitation equipment, such as a defibrillator in one room had not seen checked since early January 2024.”

Generally, the setting had improved their timely provision of medical care,.

But according to the report inspectors found that only three in ten patients were triaged within the national recommended time limit of 15 minutes, with the average being approximately 58 minutes.

Although the high demand and waiting times in emergency departments are a national issue, the inspectors noted that more could be done by the service to improve the provision of timely care.

Further improvements were required to ensure that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) discussions are accurately recorded and readily available to staff.

Response

Alun Jones, Chief Executive of Healthcare Inspectorate Wales, said: “The pressure and demand on healthcare services continues to create significant challenges for the NHS.

“During this inspection we found staff working extremely hard in challenging conditions to provide patients with safe and effective care.

“It is reassuring to see improvements have been made since our previous inspections of the department, but further improvement is still needed.

“I hope this report will provide the health board with a clear understanding of the challenges being faced by the service and support the action they need to improve.

“We will be working with the health board to ensure these improvements are made and evidenced.’

A plan has been produced by the Health Board, which contains a comprehensive set of actions to address the wide range of further improvements needed.

The service must ensure improvement measures remain in place and the processes implemented are sustainable now and in the future.

Responding to today’s report, Carol Shillabeer, Chief Executive, said: “I want to thank all staff involved in helping to improve Emergency Department services within Glan Clwyd Hospital, and particularly the staff in the department for their dedication to continuous improvement, while working under constant pressure.

“Whilst clearly there are still issues that need to be addressed, we are all committed to provide the very best care and experience possible.

“Our Emergency Departments are always extremely busy and we are looking at ways to provide services differently to help improve the waiting times and people’s experience of healthcare services.

“This report shows that tangible and positive difference is being made, whilst indicating the further improvements we are totally committed to taking forward.”