Cromer Hospital

Norfolk and Norwich University Hospitals NHS Foundation Trust operates primarily across two sites:

• Norfolk and Norwich University Hospital (NNUH) – this was built in 2001 and is based on the Norwich Research Park. Care is provided for a tertiary catchment area from Norfolk and neighbouring counties.
• Cromer and District Hospital – this was rebuilt by the Trust in 2013. It has a minor injuries unit and provides a range of outpatient and day-case services.

We carried out an unannounced focused inspection of Cromer Minor Injuries Unit (MIU) on 16 February 2022. We also had an additional focus on the urgent and emergency care pathways across Norfolk and Waveney and carried out a number of inspections of services in a few weeks. This was to assess how patient risks were being managed across the health and social care services during increased and extreme capacity pressures.

As this was a focused inspection for Norfolk and Norwich University Hospitals NHS Foundation Trust, we only inspected parts of our five key questions. For the urgent and emergency core services we inspected parts of safe, effective, responsive, caring and well-led.

The MIU has not been inspected insolation using the Care Quality Commission’s comprehensive inspection methodology, however, the service has previously been incorporated in inspections of urgent and emergency care inspections. Urgent and emergency care was previously rated as good overall with responsive rated as requires improvement.

For this inspection we considered information and data on performance for the MIU. This inspection was partly undertaken due to the concerns this raised over how the organisation was responding to patient need and risk in the emergency care and the wider trust in times of high demand and pressure on capacity. We were concerned with the waiting times for patients, delays in their onward care, treatment and delayed discharges, as well as delayed and lengthy turnaround times for ambulance crews.

We looked at the experience of patients using the MIU at Norfolk and Norwich University Hospitals NHS Foundation Trust. This included the MIU and areas where patients in that pathway were cared for while waiting for treatment or admission. We also visited wards where patients from the emergency department were admitted for further care. This was to determine how the flow of patients who started their care and treatment in the emergency department and those cared for on medical wards, was managed by the wider hospital.

A summary of CQC findings on urgent and emergency care services in Norfolk and Waveney.

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Norfolk and Waveney below:

Norfolk and Waveney

Provision of urgent and emergency care in Norfolk and Waveney was supported by services, stakeholders, commissioners and the local authority. The health and care system in this area lies across a large, predominantly rural, geographical area with a large proportion of the population aged over 65 years.

Compliance with CQC regulations has historically been challenging across Norfolk and Waveney, particularly in Acute, Mental Health and Adult Social Care services, many of which have been rated Requires Improvement or Inadequate.

We spoke to staff in services across primary care, urgent care, acute, ambulance services, mental health and adult social care. Staff told us of increased pressure across urgent and emergency care pathways, staffing issues and a lack of capacity in key sectors including GP and Dental practices and social care. These issues were resulting in inappropriate calls to 999 and attendances in emergency departments. There were delays in discharge for patients who were medically fit but unable to access appropriate packages of care to enable them to leave hospital.

We previously inspected mental health services in the Norfolk and Waveney area in November and December 2021 and found, due to an increase in referrals and staffing shortages, patients in the community had long waits to be seen. This led, in some cases, to patients deteriorating and requiring urgent and emergency treatment. In addition to this, some inpatient services (such as CAMHS) did not have available beds within the area. Patients were kept in urgent and emergency care settings whilst a bed was found. During inspections of acute services, we found patients unable to access appropriate and timely care to meet their mental health needs.

We inspected a number of GP practices and found some concerns in relation to access for patients trying to see or speak to their GP. We found high levels of staff absence resulting in some staff working long hours and experiencing increased pressure on their services.

To try and alleviate the increasing demand on Emergency Departments, GP streaming services had been introduced in EDs in Norfolk and Waveney. Patients who presented at the ED with problems which were deemed suitable for a primary care appointment could be referred to a co-located primary care service. In some cases, streaming services helped to prevent up to 33% of patients attending the ED.

We inspected urgent care services in the Norfolk and Waveney area and found these to be well-run. However, an on-going shortage of out of hours and urgent care appointments, particularly for urgent dental care, meant patients couldn’t always be appropriately signposted by NHS111. This meant patients often presented to ED for treatment. NHS111 in Norfolk and Waveney had also experienced significant staff shortages, much of which has been due to the COVID-19 pandemic. Leaders in this service had a recovery plan in place; however, staff shortages and increased demand had resulted in significant delays in call answering and call-back times in comparison to the national targets and there was also a very high call abandonment rate, meaning people ended the call before speaking to an advisor. Whilst performance across Norfolk and Waveney did not meet national targets and people experienced significant delays, these delays were, on average, shorter than regional and national averages

We inspected emergency departments (ED) in Norfolk and Waveney between December 2021 and February 2022 and found lengthy delays for people accessing emergency care. A high number of patients were waiting over 12 hours in ED resulting in overcrowding. This impacted on ambulance handovers and further delays in releasing ambulance crews into the community to respond to 999 calls.

Staff shortages have had a significant impact on social care services across Norfolk and Waveney. In addition, the provision of domiciliary care services is challenging due to the rurality of the area. At the time of our inspections, a care hotel was being utilised in Norfolk and Waveney. We spoke to healthcare professionals who had provided services to people being cared for at the hotel and found them to be safe and generally well cared for. The number of people receiving care in the hotel was small and the aim was for them to only stay for a very short amount of time before going home. This service is commissioned until the 30 April 2022, a formal evaluation will take place before any future plans are agreed.

Some social care and learning disability services in Norfolk and Waveney have struggled to achieve compliance with CQC regulations and a rating of good. Some support has been established across Norfolk and Waveney to help services improve. However, the impact of any support to date has been limited.

Staff shortages and service quality has significantly reduced capacity across social care and learning disability services in Norfolk and Waveney. This has resulted in significant delays in transferring people from hospital to their own home or an appropriate place of care. This in turn meant people who were medically fit for discharge remained in hospital delaying the admission of new patients. These delays and poor flow resulted in overcrowded EDs and an inability to transfer patients from ambulances.

Strategic, system wide workforce planning and increased community provision of health and social care is needed to meet the needs of the local population. This is needed to reduce the pressure on urgent and emergency care services and to reduce the risk of harm to people living in Norfolk and Waveney.

Summary of Norfolk and Norwich University Hospitals NHS Foundation Trust – Cromer Hospital

• The service had enough staff to care for patients and keep them safe. Staff had training and understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records.
• Managers monitored the effectiveness of the service. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs.
• People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.

However:

• Staff compliance with safeguarding children at level three fell short of the trust target.
• The capacity of the environment was not suitable for the number of people who attended.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

During the inspection we observed care, spoke with 35 members of staff and carried off site interviews with the senior leadership team. We spoke with 15 patients and one carer. We observed care provided; attended site meetings, reviewed relevant policies and documents and reviewed ten patient records.