Shropshire's hospitals trust takes its medicine

That was the scene that would have greeted the team from Government watchdog the Care Quality Commission (CQC) when it visited for a three-day inspection back in October last year.

And it is against that backdrop that Shrewsbury and Telford Hospital NHS Trust has been told it "requires improvement" in four out of five key areas in the CQC report published today.

The trust is under "enormous pressure" with regard to beds and is consistently not meeting the Government gold standard for seeing patients in A&E within four hours, the report says.

CQC inspectors said the A&E departments at both sites had "regularly" breached the waiting target. The report said the lowest result was 88 per cent in January last year – but that has since been superseded, with just 76 per cent seen in time at the start of this year.

A&E services at the Princess Royal Hospital were "safe and effective, with adequate staffing", inspectors said, but added there were "greater challenges" at the Royal Shrewsbury site.

Inspectors said the trust was below average on the handover of patient care from ambulance crew to A&E. The report said the hospitals were worse than average in terms of the percentage of emergency admissions via A&E who had to wait between four and 12 hours.

Inspectors also found a "heavy reliance" on bank and agency staff at the two hospitals due to a high number of vacancies and staff sickness in some areas.

The CQC was particularly critical about its findings on two wards at the Royal Shrewsbury Hospital.

Inspectors found "good care" delivered on its tour of medical wards, but said the high number of vacancies and reliance on agency staff was putting "considerable pressure" on full-time workers at the two sites.

The report raised concern about Ward 31 at RSH, which at the time of the inspection was being used for day surgery patients. Inspectors said the ward had no heating, no emergency call bell and raised concerns about the staffing on the ward.

In fairness to the trust's new management team, nothing that is in the report should come as any great shock to anyone following the fortunes of the Royal Shrewsbury and Princess Royal hospitals over the past year.

They have been very open about the problems and challenges facing them at regular board meetings held in public.

The crisis facing A&E at both the RSH and Telford's PRH was first laid bare at a trust board meeting in the summer of last year.

Debbie Kadum, chief operating officer for the trust, said doctors and nurses in the two A&E wards were being pushed to breaking point by the "relentless" number of people coming through the doors.

She said the two hospitals dealt with an average of 281 patients per day in April and May – well above the normal average.

It is a pattern that has continued throughout the year, with significant knock-on effects for the two hospitals.

Firstly, it has made it next to nigh on impossible for the trust to meet the Government "gold standard" of seeing 95 per cent or more of patients coming through the doors at A&E within four hours or less. The latest figures released last week showed the trust was way below at 80 per cent.

Secondly, it has had a human cost as sickness levels among nurses in particular have been consistently high. That has led to a reliance on agency staff – who can be paid double what a regular staff member is – and a massive overspend on wages. The trust is paid based on the number of patients it expects to treat every financial year.

But it does not receive extra cash if the numbers go up as they have done – a situation health chiefs claim has left them millions of pounds out of pocket.

The hospitals were given nearly £750,000 to help with rising A&E cases – but at the last count it still faced being more than £12 million in the red by April and the end of the financial year.

Papers at the last board meeting in December show the trust is forecast to be £12.2 million overspent by the end of the financial year, £4 million above target.

The £736,000 has come from Telford & Wrekin Clinical Commissioning Group, which is responsible for buying health services. But this has only improved the position by about £200,000.

Much of it has been swallowed up by a request from the CQC to increase nursing levels within the critical care service following the inspection.

The trust had planned to be overspent by nearly £4.9 million at the end of October to meet its original target, agreed with Government, of an £8.2 million end-of-year deficit. But the figures reveal it was already £8.59 million in the red at the end of October.

The board papers revealed the pay bill for October at the two hospitals was £18.2 million with an overspend of £1.3 million in nursing because of agency staff costs.

Commenting on the report today, trust chief executive Peter Herring said it was "fair and well balanced".

"It includes some real highlights as well as some things that make uncomfortable reading, which is just as we should expect in a report of such breadth and depth," he said. "It is very clear that almost universally our staff were rated 'good' for caring. That's great to hear and gives us all real confidence in the future of care in our hospitals.

"A big theme through the report is about our openness, transparency and honesty – we told the CQC where our own issues and concerns are, and these are reflected in this report.

"Staff right across the trust gave their time to share their hopes and concerns with the CQC, and patients too. We'd like to thank everyone who gave their time. We also take areas of criticism on the chin.

"For example, executive visibility needs to improve and we recognise that. Indeed we've already taken steps to begin to address this, including regular walkabouts.

"We've also taken action in other areas of concern. End-of-life care was flagged up as an area in need of development.

"We have started to make progress here – improving the viewing rooms in the mortuary at RSH, as well as bringing forward a £1.4 million refurbishment of the facility.

"It was also great to see so many services rated as good, including the women and children's services at both sites, outpatients and diagnostic imaging at both sites, and our three community midwife-led units.

"The inspectors were here at a particularly busy time, when there was a high demand on our services and in a week when there was also industrial action involving a number of trade unions."

Sarah Bloomfield, director of nursing and quality at the trust, said: "The CQC report highlights a number of areas where we need to improve and lessons for us to learn, particularly around equipment and our systems.

"But one thing that is clear throughout the entire report is the care and compassion that our staff show to our patients. The report also highlighted that patients' experiences of care were good.

"Equipment and practices can be changed quite quickly, but if we don't have caring staff who are proud to work in the NHS then we have very real problems."

Gill Stewart, director of local watchdog Healthwatch Telford and Wrekin, added: "Healthwatch Telford and Wrekin consider that the report published is fair and accurately reflects the comments we have received from the public.

"We are pleased to see that the care and compassion of staff at the hospital is recognised as being good – this is very much the feeling of patients we have spoken to."

The solution to the problems outlined in the report, health bosses hope, lies with Future Fit. It is the programme which will transform the future of hospital services in Shropshire as we know it.

Leaders of the scheme are currently drawing up a shortlist of proposed options for the most talked about component of Future Fit – the location of A&E in the county.

The shortlist will be announced soon – and for some hard-pressed staff, change cannot come quickly enough.

Critical Care: Concerns over staffing on unit

Concerns were raised by inspectors about nurse staffing levels and the number of beds being taken up at intensive care units and high-dependency units at the two hospitals.

The CQC was so concerned about staffing it asked the trust to "look at the situation immediately" following the October inspection. The report, published today, says inspectors were pleased to see the trust had responded during an unannounced follow-up visit.

It said the trust was not meeting core standards for intensive care at either site. Inspectors also raised concerns about the arrangements for on-call consultants to cover intensive care over the weekends.

It added: "An intensive care consultant was present in the ICU/HDU from 8am to 5pm, Monday to Friday. Out of hours at weekends and on nights there was an on-call consultant rota to provide cover in critical care, but they might not be an intensive care specialist."

End-of-Life: Mortuary in need of new facilities

In November last year hospital bosses announced plans for a £1.4 million upgrade of the mortuary at Royal Shrewsbury Hospital, prompted in part by the findings of inspectors.

The CQC report said there was "still much more to be done" in terms of end-of-life care.

Inspectors were particularly concerned about the "safety and effectiveness" of the mortuary arrangements, particularly at the Shrewsbury site.

It said facilities for bereaved relatives to view deceased loved ones were "not conducive to their needs", particularly for children.

The report says: "Staff had recognised this and had made some provisions but acknowledged the areas were not fit for purpose."

Inspectors told trust bosses they had to improve the environment around the mortuary at RSH and review it at Princess Royal.

Management: Criticism over links with staff

Inspectors spotted an "obvious disconnect" between the senior management team and rank-and-file staff at the two hospitals, the report says.

It was described as a "permafrost" by trust chief executive Peter Herring when speaking to the CQC during the October inspection and inspectors said they could not see any evident plans to resolve it.

The report said the chief executive and other senior managers said they struggled to get "frontline staff" engaged in their strategy and vision. But inspectors said staff had good ideas to improve the service which were "not being heard by the senior team".

Most staff told inspectors they knew who the director of nursing was, and could name the chief executive.

But a number of staff at both sites, but more predominantly at the Princess Royal in Telford, told inspectors that they did not have much interaction with the chief executive.

Caring Staff: Pat on the back for hospital workers

Staff at the two hospitals, by and large, came out of the inspection report with a glowing pat on the back.

Inspectors who visited the Royal Shrewsbury and Princess Royal said, although there were some exceptions, staff were "caring and compassionate" and treated patients with "dignity and respect".

The CQC team also praised the way staff communicated with patients in a way that helped them understand about their care and treatment, and was pleased to see "many examples of emotional support" to patients and relatives.

The report said staff responded in a timely manner to patients who needed help or assistance and that nurses, doctors and other staff were able to demonstrate an understanding of the individual needs of patients.

Nursing and medical staff ensured that "privacy was maintained and dignity respected" when carrying out examinations and providing care, the report said.