Improvements Noted, Although Challenges Remain for Wrexham Maelor’s Emergency Department

The inspection identified sustained systemic challenges impacting the department, including high demand and poor patient flow through the hospital due to delays in discharging patients. However, inspectors noted several positive improvements since the previous inspection in August 2022. This included improved nurse and medical staffing levels, as well as a reduced reliance on agency staff, which has helped maintain continuity and department knowledge. Inspectors noted an improved culture within the department, which was positive, supportive, and inclusive.

However, the inspection identified several patient safety concerns requiring immediate action. These included expired medicines, and IV fluids not stored correctly in their original packaging. 

Inspectors acknowledged staff were working under challenging conditions, and delays in patient discharge resulted in some patients spending over 36 hours in the department. While improvements have been made since the previous inspection, we recommended further initiatives to improve patient flow and address national pressures on emergency departments.

The waiting area and other areas of the ED were found to be relatively calm, despite the high number of patients being accommodated. Patients with urgent and high-risk conditions were quickly escalated and moved to the appropriate treatment areas. Specialist support was effective, with doctors responding promptly to assessments. Delays were noted in offloading patients from ambulances; however, these delays are being managed with appropriate escalation procedures in place. 

Inspectors found that not all patients were triaged within the recommended 15-minute window upon arrival, and there were instances where repeat patient observations were not consistently carried out or recorded. The health board must ensure that triage is done promptly, and patient observations are regularly conducted and documented to maintain patient safety.

Staff were working hard to maintain patient privacy and dignity, although this was more challenging for those cared for on trolleys in corridor areas. The health board must continue its efforts to minimise the use of corridor spaces for patient care. However, patient feedback was largely positive, with many praising staff for their professionalism and dedication. 

The inspection found that the department was clean and tidy, with good infection prevention and control measures in place. However, there were instances where patients with potentially transmittable infections were not isolated. The health board must ensure patients presenting with potentially transmittable infections are appropriately accommodated to reduce the risk of cross-infection.

Inspectors found the furniture in the mental health assessment room posed self-harm risks and was unsuitable, though staff ensured patients were supervised. The health board must replace the furniture to ensure patient and staff safety and address ligature risks. Additionally, falls and skin pressure risk assessments were not consistently completed for patients.

When reviewing patient records most were electronic, however, documentation completed by specialist doctors were still in paper format, making it difficult to get a full overview of patient assessments and treatments. We recommend implementing a health board-wide electronic records system to improve information sharing and patient care.

Inspectors saw staff striving to provide care in a way that promoted and protected people’s rights, regardless of their gender or background. Patients could provide feedback directly to staff, and there were formal systems for managing complaints, aligned with the NHS Wales Putting Things Right process. 

There were examples of good partnership working between various staff disciplines and professions within and external to the department, including pharmacy, occupational therapy and physiotherapy services. The leadership team was committed to service improvement, with senior nursing staff providing assistance during high-pressure times. However, staff expressed the need for increased visibility from senior management external to the department. We have asked the health board to consider the staff comments and consider how improvements can be achieved in response.

Alun Jones, Chief Executive of Healthcare Inspectorate Wales, said:

          The dedication and professionalism of staff at Wrexham Maelor Hospital’s Emergency Department is evident, whilst working under challenging conditions. While progress has been made since our last inspection, significant challenges remain. Like many NHS Emergency Departments across Wales, Wrexham Maelor is under considerable pressure. Addressing systemic issues around patient flow and care delivery is essential to ensure safe and timely care. We will continue to work with the health board to ensure the recommendations are implemented to drive improvements in patient care.

• December 2024 - Hospital Inspection - Emergency Department – Wrexham Maelor Hospital, Wrexham