ICS told to increase help for trust that treated patients on the floor

The Care Quality Commission said Devon ICS must give more “input” to University Hospitals Plymouth Trust, where inspectors warned staff could “not ensure the safety of all patients” arriving at the emergency department.

During a visit to the trust’s Derriford Hospital in September, inspectors saw staff treating six patients who “lay on the floor” of the ambulatory assessment unit, while another patient who had been in the department overnight was being “treated/assessed in the ‘storeroom’” – according to the CQC’s report.

Inspectors reported: “The department was overcrowded, there was no seating available… Social distancing was not possible.”

The unit is within UHP’s ED, which trust CEO Ann James described to HSJ as “really out of date”. The trust wants to expand its ED under the New Hospitals Programme. 

While the CQC praised senior leaders in the ED and executive chiefs for being “open to challenge” and “understanding the problems” faced by the urgent and emergency care service, inspectors said there was only so much the trust could do alone.

Catherine Campbell, head of hospital inspection at CQC, said: “The impact of a high number of patients attending to receive care, combined with reduced staffing levels in the ED, created issues that the trust couldn’t solve alone and further support was needed from the local health and social care system.

“We… know that the trust is trying to work in partnership with the wider care system to resolve the issues, but they can’t do it alone and there needs to be more input from the local healthcare system to ensure these problems are alleviated for people using services.”

The CQC has, therefore, imposed a condition on the trust’s registration which requires UHP to “take action with the health and social care system to improve patient safety and experience”.

In an interview with HSJ, UHP CEO Ann James said the problems with patient flow were occurring “not through any lack of effort, commitment or goodwill” from health and social care partners in Devon, and she stressed the trust had “really good relationships” across Plymouth and the ICS.

She said the ICS, including UHP itself, needs to focus on “not multiple priorities but a number of things that really help move the system forward in a sustainable way”.

Asked what she wanted the ICS to do for UHP which it wasn’t currently doing, Ms James said she wanted the ICS to be “very clear on the priorities [ahead], to be very clear about the actions that underpin those priorities, and to be really open to evaluate whether those actions are having the impact on the scale that is needed”.

The trust currently has around 125 patients – amounting to around 11 per cent of its bed-base – waiting longer than 24 hours to be discharged to another care setting.

“Being able to discharge five, six, seven patients is really great but it’s the 124 that we really need to be able to sustain,” Ms James said.

“It’s about making sure the patients presenting to ED who don’t need traditional ED services have sustainable alternatives to go to. That’s what I want the ICS to focus on.”

Ms James pointed to Plymouth’s high levels of deprivation and said the city sees “coastal, urban and rural deprivation” which puts extra pressure on the trust.

She also warned that domiciliary and care home staff were leaving the sector to work in the hospitality and tourism industries which was contributing to a “chronic shortage of staff across the system”.

A review of Devon’s NHS leadership in 2019 - revealed by HSJ  - found that health chiefs in Devon shared a sense of “learned helplessness” and a habit of “retrenching” back into their organisations when challenges across the ICS arose.

Asked if this was still an issue two and a half years on, Ms James said the ICS had made “huge progress in working collectively”.

“But clearly when we’ve got ambulances waiting outside ED, patients waiting at home for ambulances, patients waiting in hospital when they should be somewhere else, and large numbers on the waiting list, we have to be absolutely determined to face into those challenges.”

She added: “It is unusual but reflective of the national pressures for CQC to comment on the fact that a hospital can only do so much… We need that bigger system contribution to get us to a sustainable position.”

Speaking on behalf of Devon’s health and care system, Darryn Allcorn said the wider health and care system had commissioned extra beds in “care hotels”, offered personal health budgets so “friends and family can be freed to offer support at home”, and provided financial incentives for existing care workers – as well as launching a recruitment campaign to attract more people to the sector.

“UHP was also recently awarded a contract for providing community and adult social care serivces as an integrated care partnership, so that services can work more cohesively to keep people out of hospital and help them to get home.

“However covid-19 continues to have an impact across the wider health and care system, with more staff absent due to [it] and some care homes closed to admissions due to outbreaks.”