Emergency Department at Ysbyty Glan Clwyd shows signs of improvement but challenges remain

In May 2022, the department, run by Betsi Cadwaladr University Health Board, was designated as a Service Requiring Significant Improvement (SRSI). HIW’s SRSI process aims to identify service failures, to drive forward urgent improvement. This designation was based on an accumulation of evidence, leading to an unannounced onsite inspection in May 2022. A follow-up inspection then took place in November 2022, which noted only minimal improvement, therefore the designation remained in place. 

During the recent inspection over three consecutive days in April/May 2024 we found a marked improvement within the areas of significant concern identified in 2022. These areas included the timely escalation of patients with critical and high-risk conditions, and strengthened oversight of the waiting area compared to previous inspections. Overall, inspectors highlighted an improved culture, an increasing in staffing levels and stronger leadership.

As a result of these key improvements, HIW has decided to de-escalate the department as a SRSI. Despite the de-escalation, several issues remain for the service which continues to operate in highly demanding and challenging conditions. Areas of concern included excessive waiting times, inadequate processes for the assessment of patients, issues with medication management, and insufficient checks of life-saving equipment.

We noted that oversight of the unit’s waiting room had improved with patient emergencies escalated and well managed. Overall, the department was clean and tidy, with robust infection prevention and control measures in place; and general health and safety risks assessed. 

However, we were concerned that pressure and demand within the department was leading to an increased risk to patients. A key issue identified was poor patient flow throughout the hospital. Patient flow is the movement of patients through a healthcare system from the point of admission to the point of discharge. 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. However, their discharge was delayed for various reasons such as waiting for further rehabilitation, a care package to be put in place or a placement in another care facility. 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 us they had waited up to 48 hours and had not been informed or updated on their care and treatment plans.

Inspectors saw evidence of strong staff communication during shift handovers, and good working relationships within the department and with ambulance staff. Inspectors witnessed positive staff to patient interactions, with staff treating patients with dignity and respect, despite challenging conditions. Staff ensured that patients were given as much say as possible regarding their treatment plans. Patients could provide feedback about the service, and there was a good system in place for recording and managing complaints.

We 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. 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, on-going assessments, and monitoring. However, 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. We acknowledge high demand and waiting times within Emergency Departments is a national issue, but inspectors felt 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. It is important that these discussions, and the decisions made, happen in a sensitive and effective way to respect the wishes and views of all of those involved. 

The department had a robust electronic records management system in place; however, some non-electronic patient notes were stored together, which increased the risk of staff confusion and potential delays. However, it was positive to see robust escalation procedures in place to safeguard patients who leave the department without being seen or against medical advice. 

Since the previous inspection, the completion rates for mandatory staff training had improved; and there was good visible leadership within the department. It was encouraging to see staffing levels had also improved, and there was less reliance on agency staff.

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.

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.’

April and May 2024 - Hospital Inspection Report: Emergency Department - Ysbyty Glan Clwyd

Emergency Department, Ysbyty Glan Clwyd – Betsi Cadwaladr University Health Board - De-escalation - Service Requiring Significant Improvement