Patients visiting Wales' newest emergency department were likely to have been put at risk of harm due to the lack of processes and systems in place, inspectors found. Healthcare Inspectorate Wales (HIW) carried out an unannounced inspection of The Grange University Hospital in Cwmbran between November 1 and 3 last year and published its findings on March 29.
On the day of their arrival inspectors said The Grange was at full capacity with no empty beds in A&E or in the hospital in general. Despite the best efforts of staff who were "working hard under pressure" the report stated the emergency department had several issues which could have compromised the privacy and dignity of patients. This included problems with the physical environment of the waiting room, which was described as a "major cause of anxiety" for visitors, as well as with the flow of patients through the hospital in general.
It found that patients were not triaged and medically managed in A&E in a timely fashion with many being placed on uncomfortable chairs or in corridors for hours on end. Between April 1, 2021, and November 1, 2021, the average waiting time in the department was six hours and seven minutes.
The report said some issues required immediate action including the fact patients in the waiting area were often left to "deteriorate without being overseen". There were also infection control failures which could have led to the cross-contamination of Covid-19. "We were not assured that all the processes and systems in place were sufficient to ensure that patients consistently received an acceptable standard of safe and effective care," the report stated.
Staff were also asked to give their feedback on working in the A&E department with many stating that they felt they could not offer the highest level of care due to lack of staffing, poor leadership, and low morale. One stated: "Patients are deteriorating and spending days in chairs with complaints that are inappropriate to sit out with." Another added: "They know it's overcrowded and understaffed …It's soul-destroying working there…Staff are just leaving all the time."
One worker stated: "Since the move to The Grange I no longer feel pride and a sense of achievement in my work. Work pressures and lack of staff mean I dread going into work and don't feel I give a good standard of care. There are too many patients most shifts with unsafe levels of appropriately-trained staff to care for them and I fear that serious incidents will occur because of this."
One employee said they would not take their children to the A&E at The Grange and added: "It's dangerously understaffed, too small for the capacity, and I fear nursing staff are going to have a serious incident on their hands the further into the winter we go. Staff are off sick including myself – I had two months off with work-related stress. As a senior member of the team I felt useless in trying to escalate staff concerns and the safety of our patients. There are many times I fear a mum arriving with a baby not breathing and I don't have the space nor staff to put them or that a child deteriorates without us noticing due to having so many other patients. You just can't physically get around every patient. Observations are missed, medications are missed."
Inspectors also found that the emergency unit needed to reduce its reliance on agency and bank staff as well as increase the mandatory training and appraisals given to its own staff. Despite these range of concerns the inspectors did find positives too including the feedback given by some patients. During their inspection 84% of patients rated the service as 'very good' or 'good'. However 16% described it as 'poor' or 'very poor'.
The report stated: "Most patients rated the quality of the patient experience provided during their stay in hospital as very good and were complimentary about the staff in the patient survey completed. Patients, including those on ambulances, were provided with food and drinks during their time at the unit."
One patient responded in the survey: "Staff were very lovely and respectful despite the amount of patients they had," while another added: "The nursing staff are amazing however definitely overworked – they run around all night."
Staff also told inspectors that there was a lack of appropriate private rooms available in A&E which resulted in delays in taking medical assessments. The admitted intravenous infusions and blood-taking occasionally took place in the corridors when there was no available clinical space. The report stated: "There were multiple instances observed of staff apologising to patients for the long waiting times. Staff felt frustrated that patients were being nursed in an inappropriate area and that their personal care standards were being compromised. Staff we spoke with said that this level of care was affecting staff and potentially leading to a state of physical and emotional exhaustion.
"We also noted that the microphones on the reception desk were not working properly. They were at waist level on the counter and patients had to shout with their personal details to the receptionists. This created issues with privacy and dignity for the patients."
On the day the inspectors arrived at the emergency department they said there were approximately 20 ambulances waiting to move patients from the ambulances into A&E. The report stated: "Overnight during the inspection we noted that there had been two patients waiting for 10 hours in an ambulance without a medical assessment. Both patients were clinically stable, they had been triaged, and had received analgesia." It added: "All Welsh Ambulance Service staff we spoke to had examples of ambulance delays in the community leading to delayed treatment and patient harm."
The Grange University Hospital, which cost £350m to build, opened its doors for the first time in November 2020, four months ahead of schedule. It centralised many critical care and specialist services, including A&E, previously provided at the Royal Gwent Hospital and Nevill Hall Hospital. But ever since its premature opening the emergency department has experienced a number of major issues.
On Tuesday, March 29, Aneurin Bevan University Health Board, which runs The Grange, announced that its NHS services were under "sustained and unprecedented pressure" and could not be stabilised. It meant that a state of "business continuity", commonly known as a "black alert", was declared. It called on people to only attend A&E if they had a life-threatening illness or serious injury.
In response to the report a spokesman for Aneurin Bevan University Health Board said: "We’re pleased to see that the report highlights the professionalism of our staff and that patients were treated with courtesy, dignity, and respect. During the inspection HIW identified some areas where 'immediate assurance' was required and these matters were addressed promptly. We also have an action plan to focus on the other recommended areas for development.
"HIW have also indicated that improvements to patient flow are required which is a nationally-recognised problem exacerbated by the ongoing Covid pandemic. The health board has since implemented an urgent care improvement plan. However it’s important to recognise that the challenges associated with emergency department overcrowding and delayed transfers of care are ongoing.
"We’re sorry for the experiences of the patients whose care has fallen below our usual standards and to those who are experiencing delays in their care. We're incredibly thankful to our staff who are working under significant and sustained pressure in such challenging circumstances."
