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Royal Shrewsbury Hospital

Overall: Requires improvement read more about inspection ratings

Mytton Oak Road, Shrewsbury, Shropshire, SY3 8XQ (01743) 261000

Provided and run by:
Shrewsbury and Telford Hospital NHS Trust

All Inspections

10 and 11 October 2023

During a routine inspection

The Royal Shrewsbury Hospital is part of Shrewsbury and Telford Hospitals NHS Trust and provides acute services to those living in Shrewsbury and surrounding areas.

Services at the Royal Shrewsbury Hospital include urgent and emergency care services, emergency medicine and surgery and end of life care services. Along with diagnostic and screening, critical care and outpatient services.

The urgent and emergency care service provides services 24 hours a day, seven days a week. The service consists of a booking reception area, a main waiting area, a children’s waiting area, two adult triage rooms, four bedded resuscitation bay, 12 majors’ cubicles, ‘pit stop’ with four trolleys, four bedded clinical decisions unit (CDU), one children’s cubicle and one children’s triage room.

The hospital’s medical care services comprised of cardiology, renal, respiratory and dermatology, stroke, care of the elderly and neurology, diabetes and endocrine, clinical support services, oncology and haematology.

The end of life care service comprised of two service lines, a specialist palliative care team and an end of life care team. The palliative care team at Shrewsbury and Telford Hospitals NHS Trust works across both hospitals. They provide specialist advice and support to people living with a serious, life-limiting illness who are currently staying in either the Royal Shrewsbury Hospital, or the Princess Royal Hospital in Telford. In-patients who might benefit from the service can be referred to the hospital palliative care team by any healthcare professional, carer or community team.

6 July 2021

During a routine inspection

The Royal Shrewsbury Hospital is part of Shrewsbury and Telford Hospitals NHS Trust and provides acute services to those living in Shrewsbury and surrounding areas.

Services at the Royal Shrewsbury Hospital include urgent and emergency care services, emergency medicine and surgery and end of life care services. Along with diagnostic and screening, critical care and outpatient services.

The urgent and emergency care service provides services 24 hours a day, seven days a week. The service consists of a booking reception area, a main waiting area, a children’s waiting area, two adult triage rooms, four bedded resuscitation bay, 12 majors’ cubicles, ‘pit stop’ with four trolleys, four bedded clinical decisions unit (CDU), one children’s cubicle and one children’s triage room.

The hospital’s medical care services comprised of cardiology, renal, respiratory and dermatology, stroke, care of the elderly and neurology, diabetes and endocrine, clinical support services, oncology and haematology.

The end of life care service comprised of two service lines, a specialist palliative care team and an end of life care team. The palliative care team at Shrewsbury and Telford Hospitals NHS Trust works across both hospitals. They provide specialist advice and support to people living with a serious, life-limiting illness who are currently staying in either the Royal Shrewsbury Hospital, or the Princess Royal Hospital in Telford. In-patients who might benefit from the service can be referred to the hospital palliative care team by any healthcare professional, carer or community team.

During our inspection we visited all areas within urgent and emergency care, ward 22 (short stay), 22 (respiratory), 23, 28 (frailty and gen med), 27 (general med), 23 (oncology), 24c (cardiology), 24E (endocrinology), 32 (respiratory), 35 (nephrology), 36, acute medical unit, surgical assessment unit and endoscopy.

We spoke with 86 members of staff, including doctors, nursing staff of various grades, healthcare support workers, physiotherapists and managers. We spoke with 21 patients and we looked at 79 sets of patient records.

09 to 10 Jun 2020

During an inspection looking at part of the service

Our rating of services went down. We rated them as inadequate because:

During this inspection we used our focused inspection methodology. We did not cover all key lines of enquiry. We have rated the service as inadequate and have taken enforcement action as a result of this inspection to promote patient safety. Our enforcement action included the use of our urgent enforcement powers where we placed conditions on the trust’s registration in relation to the assessment and management of risk, care planning, and incident management. We also served two warning notices to the trust requiring them to make improvements in the following areas; end of life care staffing, end of life staff competencies, end of life governance systems and the way the staff support patients in line with their personal preferences and individual needs.

  • Staff did not always complete risk assessments for each patient in a prompt manner. Action was not always taken to remove or minimise risks to patient’s health and wellbeing. Safety incidents were not always managed well to protect patients from avoidable harm.
  • Staff did not always keep detailed records of patients’ individual needs, preferences and the care and treatment provided. Person centred care was not always planned for to ensure patient’s individual care needs and preferences were met.
  • The end of life care service did not ensure that all staff were competent for their roles, placing patients at risk of receiving unsafe and inconsistent care. This had not improved since the last inspection.
  • The services did not always provide care and treatment based on national guidance and evidence-based practice.
  • Staff did not consistently support patients who lacked capacity to make their own decisions or were experiencing mental ill health in line with legislation and national guidance. At times, patients continued to be unlawfully restricted.
  • Leaders did not demonstrate that they had the skills and abilities to run the services. They did not demonstrate that they understood and managed the priorities and issues the service faced. They were not always visible and approachable in the service for patients and staff.
  • The culture of the services was not centred on the needs and experience of patients.
  • The services did not operate effective governance systems to improve the quality of services. Leaders had not effectively implemented new ways of working to drive improvement and they were not always available to provide day to day support to staff. This had not improved since the last inspection.
  • Staff did not keep detailed records of patients’ preferences for care and treatment provided at the end of their life. This had not improved since the last inspection.
  • The end of life care service did not have the enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. This had not improved since the last inspection and was identified at our inspection in 2018.
  • Specialist palliative care services were not available on site seven days a week to support timely patient care. This had not improved since the last inspection.
  • It was possible that palliative and end of life care patients could be missed due to the lack of systems to identify patients. This had not improved since the last inspection.

17 Feb 2020 to 18 Feb 2020

During an inspection looking at part of the service

Our rating of services stayed the same. We rated them as inadequate because:

We carried out an unannounced focused inspection of the emergency department at Royal Shrewsbury Hospital on 17 February 2020, in response to concerning information we had received in relation to care of patients in this department.

We did not inspect any other core service or wards at this hospital, however we did visit the admissions areas to discuss patient flow from the emergency department. We also undertook an unannounced inspection of Princess Royal Hospital, Telford on 18 February 2020 which has been reported separately.

During this inspection we inspected using our focused inspection methodology. We did not cover all key lines of enquiry however we have rated this service in accordance with our enforcement policy.

This was a focused inspection to review concerns relating to the emergency department. It took place between 12pm and 8pm on Monday 17 February 2020.

We found:

The design, maintenance and use of facilities, premises and equipment did not keep people safe.

Staff did not consistently apply control measures to protect patients, themselves and others from infection risks.

Staff did not always promptly identify and quickly act upon patients at risk of deterioration. Staff did not always complete risk assessments for each patient in a prompt manner. They did not always act to remove or minimise risks or update the assessments when risks changed.

The service did not have enough permanent nursing staff with the right qualifications, skills, training and experience to consistently keep patients safe from avoidable harm and to provide the right care and treatment. However, staffing gaps were filled with temporary bank and agency staff.

The service did not have enough permanent medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

The service was not designed or delivered in a manner that respected patients’ privacy and dignity. Staff did not always have the time to interact with people in a meaningful way.

People could not always access the service when they needed to, and they did not always receive the right care promptly. Waiting times from arrival to treatment and arrangements to admit, treat and discharge patients fell well below national standards.

Leaders did not have the skills and abilities to run the service in a safe and effective manner. Leaders did not understand and manage the priorities and issues the service faced. Senior leaders were not always visible and approachable in the service for patients and staff.

The service did not have a clear vision for what it wanted to achieve or an effective strategy to turn it into action. However, senior leaders engaged with stakeholders regarding the planning of future ED services.

Leaders in the ED did not operate effective governance processes throughout the service. The service did not always identify, escalate and mitigate relevant risks and issues.

Staff did not always feel respected, supported and valued.

Importantly, the trust must:

Action the hospital MUST take to improve

Ensure that staff comply with nationally recognised infection control standards.

Ensure patients are risk assessed in a timely way and that risks associated with the delivery of health care is mitigated as far as is reasonably practicable.

Ensure there are enough numbers of staff across all professions and grades with the right skills, competency and experience, are always employed and deployed . This includes but is not limited to ensuring there are enough numbers of competent staff to care for infants and children.

Ensure staff comply with local early warning systems to ensure patients at risk of deterioration are recognised and treated within defined time scales.

Ensure patients can access care and treatment in a timely way.

Ensure there are robust governance processes in place which assist in evaluating and improving the quality of care provided to patients accessing the emergency care pathway.

Ensure patients requiring time critical medicines are clinically assessed and such medicines are prescribed and administered in a timely way.

Ensure patients are treated with dignity and their privacy is always protected .

Ensure patients are managed in an environment which is fit for purpose.

Professor Edward Baker

​Chief Inspector of Hospitals

12 November 2019 to 10 January 2020

During a routine inspection

Our rating of services improved. We rated it them as requires improvement because:

  • The safe key question improved to requires improvement.
  • Effective key question remained as requires improvement.
  • Caring key question went down to requires improvement.
  • Responsive remained as requires improvement.

Well led key question improved to requires improvement.

16 April 2019

During an inspection looking at part of the service

Shrewsbury and Telford Hospital NHS Trust (SaTH) is the main provider of acute hospital services for Shropshire, Telford & Wrekin and mid Wales. The trust provides care from multiple locations, but there are two main hospital sites, which are The Princess Royal Hospital in Telford and the Royal Shrewsbury Hospital in Shrewsbury.

We carried out an unannounced focused inspection of the midwife led unit at Royal Shrewsbury Hospital on 16 April 2019, to review the assurances we had received relating to conditions imposed on the trust’s registration following inspection in August 2018. The conditions imposed on the registration included:

  • The registered provider must ensure that there is an effective system in place to ensure effective and continued clinical management for low and high-risk patients who present to the midwifery services in line with national clinical guidelines. This includes cardiotocography (CTG), Modified Early Obstetric Warning System (MEOWS), reduced foetal movement and triage guidelines. The provider must ensure that trust guidelines include a clear escalation plan to secure timely review from medical staff.

  • From 14 September 2018 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing the system in place for effective clinical management of patients presenting at the midwifery services at The Princes Royal and Royal Shrewsbury Hospitals. The report must include the following:

  • The actions taken to ensure that the system is implemented and effective.

  • The actions taken to ensure the system is being audited and monitored and continues to be followed.

  • The report should include results of any monitoring data and audits undertaken that provide assurance that an effective clinical management system is in place, and patients are escalated appropriately for medical support and review in line with national clinical guidelines.

We did not inspect any other core service or wards at this hospital. During this inspection we inspected using our focused inspection methodology and inspected specific key lines of enquiry within the safe and well led domains.

We met members of the maternity team on duty whilst on site. We looked at the environment, reviewed care records and other documentation.

During our inspection, we spent time on the midwife led unit to ensure improvements had been made to ensure it was safe and fit for purpose. We reviewed midwifery staffing levels to see if they had improved to meet the needs of women and ensure women and babies were safe. There were plans to improve staffing levels, however, they had not been fully implemented which meant there continued to be staffing concerns at the unit.

We reviewed National Institute of Health and Care Excellence (NICE) operational policies and guidelines to ensure they were reviewed and in date. Policies and guidelines documentation had improved; however, staff did not use the updated National Early Warning Score (NEWS 2) which had been revised by The Royal College of Physicians in December 2017. The deadline for NHS providers to adopt the tool was by March 2019. This meant they were not using the most up to date version to keep women safe.

We also checked midwives followed policy and had safety devices when working alone. For example, mobile phones to allow flexibility of access to patient information as well as for use as a lone working device to keep staff and women safe. This continued to be of concern because the system had not been fully implemented

We found improvements in managing women with higher risks in pregnancy. We checked that women at high risk were appropriately escalated and received a medical review without delay. Women with high risks relating to their birth were seen at the Princess Royal Hospital. This process ensured that early escalation of risk was identified and reviewed by senior midwives and medical staff. We checked policies on reduced foetal movements so there was a clear and defined pathway for midwives and sonographers to follow.

There were areas of poor practice where the trust must make improvements.

Action the trust MUST take to improve:

  • The trust must ensure midwife staffing is improved to ensure women receive safe and high-quality care and treatment.

  • The trust must ensure all risks are assessed, managed and mitigated through good governance systems and in line with up to date guidance.

Action the trust SHOULD take to improve:

  • The trust should ensure the birthing room is adequately staffed and has timely access to the right equipment to ensure women had the choice to use the rooms safely.

  • The trust should ensure staff receive appropriate leadership to support them in running a safe and effective service to people who chose the unit for their needs.

  • The trust should use the latest version of the National Early Warning Score (NEWS), which was updated in December 2017.

  • The trust should ensure staff have access to mobile phones to allow flexibility of access to patient information as well as for use as a lone working device to keep them safe.

We took enforcement action at Royal Shrewsbury Hospital and issued requirement notices for breaches of regulations 17 and 18.

Services at the midwife led unit at the Royal Shrewsbury Hospital are currently suspended.

Professor Edward Baker

Chief Inspector of Hospitals

16 April 2019

During an inspection looking at part of the service

This was a focused inspection to review concerns relating to the emergency department. It took place between 9am and 4pm on Tuesday 16 April 2019.

We did not inspect the whole core service therefore there are no ratings associated with this inspection. We also inspected the Princess Royal Hospital as part of this inspection. Due to the nature of services and same leadership team, there are similarities across both location reports.

Our key findings were:

  • The department implemented patient safety initiatives including early warning systems and patient safety checklists however staff did not consistently use these.
  • Provision for children was limited, in part due to the consolidation of children’s services to The Princess Royal Hospital. Clinical oversight of children in the department was limited, with poor line of sight of the children’s waiting area for example.
  • Streaming processes were limited and lacked appropriate standard operating procedures. There was limited clinical oversight of the adult waiting room which meant patients were at risk of deteriorating without being noted by clinical staff.
  • We noted an occasion when non-clinically trained staff directed a patient away from the emergency department without retaining any record of contact with the patient.
  • Compliance against constitutional standards remained a challenging. Local escalation protocols failed to deliver the necessary action to decompress the emergency department.
  • There remained a focus on delivering performance and avoiding twelve-hour breaches as compared to providing holistic care to patients; this was compounded by continued challenges around bed capacity and the estate.
  • Whilst clinical governance processes existed, the information used to provide assurance was not sufficiently robust.

As a result of this inspection, we opted to utilise our enforcement powers and imposed urgent conditions of the Provider’s registration. Namely,

  1. The registered provider must ensure that within three days of this notice, it reviews and implements an effective system with the aim of ensuring that all children who present to the emergency department are assessed within 15 minutes of arrival in accordance with the relevant national clinical guidelines.
  2. The registered provider must ensure that the staff required to implement the system as set out in the previous condition are suitably qualified and competent to carry out their roles in that system, and in particular to undertake triage, to understand the system being used, to identify and to escalate clinical risks appropriately.
  3. The registered provider must ensure that the system makes provision for effective monitoring of the patient’s pathway through the department from arrival.
  4. The registered provider must provide the Commission with a report setting out the steps it has taken to implement the system as required in conditions two to three, within five days.
  5. The registered provider must ensure there is a system in place which ensures that all children who leave the emergency department without being seen are followed up in a timely way by a competent healthcare professional.
  6. From 26 April 2019 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing the system in place for effective management of children through the emergency care pathway. The report must also include the following:

a. The actions taken to ensure that the system is implemented and is effective.

b. Action taken to ensure the system is being audited monitored and continues to be followed.

c. The report should include results of any monitoring data and audits undertaken that provide assurance that a process is in place for the management of children requiring emergency care and treatment.

d. The report should include redacted information of all children who left the department without being seen; details of any follow-up and details of any harm arising through the result of the child leaving the department without being seen.

  1. The registered provider must ensure that within three days of this notice, it implements an effective system with the aim of ensuring that all adults who present to the emergency department are assessed within 15 minutes of arrival in accordance with the relevant national clinical guidelines.
  2. The registered provider must ensure that the systems in place across the department can account for patient acuity and the location of patients at all times.

The trust must also ensure

They operate an effective clinical governance process which is supported by reliable and tested information and datasets.

Ensure staff receive feedback on incidents and outcomes from morbidity and mortality reviews.

Ensure staff comply with local hand hygiene and infection control protocols.

Professor Edward Baker

Chief Inspector of Hospitals

21 August to 21 September 2018

During a routine inspection

Our rating of services went down. We rated them as inadequate because:

  • Our rating of safe was inadequate overall. Services did not always manage patient safety incidents well. The deteriorating patient was not always recognised within urgent and emergency care services to ensure appropriate and timely care was provided. Not all services had sufficient numbers of permanent staff with the right qualifications, training and experience to keep people safe from avoidable harm and abuse. Staff completion data for mandatory training did not meet the trust targets, including Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards. There was no data available for adult safeguarding training for medical staff.
  • Our rating of effective remained requires improvement overall. Services monitored the effectiveness of care and treatment and used the findings to improve them. However, effective action was not always taken in response to poor audit results to drive improvement.
  • Our rating of caring remained as good overall. Staff delivered compassionate care and patients’ privacy and dignity was maintained.
  • Our rating of responsive remained as requires improvement overall. The trust did not always plan and provide services in a way that met the needs of local people. Not all services always took into account the individual needs of patients.
  • Our rating of well-led went down to inadequate overall. Staff reported a disconnect between them and the senior management team and board. There were systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. However, timely and effective action was not always taken to mitigate risk. The trust did not always use a systematic approach to continually improve the quality of its services or safeguard high standards of care by creating an environment in which excellence in clinical care would flourish.

12 – 15 December 2016

During an inspection looking at part of the service

Shrewsbury and Telford Hospital NHS Trust is the main provider of district general hospital services for nearly half a million people in Shropshire, Telford & Wrekin and mid Wales; 90% of the area covered by the trust is rural. There are two main locations, Royal Shrewsbury Hospital in Shrewsbury and Princess Royal Hospital in Telford. The trust also provides a number of services at Ludlow, Bridgnorth and Oswestry Community Hospitals.

Royal Shrewsbury Hospital was formed in 1979 after a number of hospitals in the town were closed or merged. The hospital provides a wide range of acute hospital services, including accident and emergency, outpatients, diagnostics, inpatient medical care and critical care. The hospital is also the main centre for acute and emergency surgery, and has a trauma unit that is part of the region-wide network. It is the main centre for oncology and haematology.

This was a focused inspection, following up our inspection that took place in October 2014. At that time the hospital was rated as requires improvement overall, with caring as good.

We rated Royal Shrewsbury Hospital as requires improvement overall.

  • The trust was not achieving the Department of Health’s target to admit, transfer or discharge 95% of patients within four hours of their arrival in ED.

  • The trust’s referral to treatment time (RTT) for admitted pathways for surgery have been lower than the England overall performance since September 2015.

  • Insufficient numbers of consultants and middle grade doctors were available.

  • Nursing staff vacancies were affecting continuity of care and an acuity tool was not used to assess staffing requirements.

  • The triage process for patients brought in by ambulance was inconsistent and unstructured.

  • Compliance with the trust target for completion of staff appraisals was below the trust target.

  • There were three Never Events relating to retained products following surgery,

  • Current safety thermometer information was not displayed on the wards

  • The maternity specific safety thermometer was not being used to measure compliance with safe quality care.

  • Inconsistencies were identified in the application of the World Health Organisation’s (WHO) ‘five steps to safer surgery’ checklist.

  • Mortuary staff decontaminated surgical instruments manually; this exposed staff to unnecessary risk and did not provide a high level of disinfection.

  • Mental capacity documentation had not been completed for defined ceiling of treatment decisions when a person had been deemed as lacking capacity.

However, we also saw that:

  • Openness and transparency about safety was encouraged. Incident reporting was embedded among all staff, and feedback was given. Staff were aware of their role in duty of candour.

  • In every interaction we saw between nurses, doctors and patients, the patients were treated with dignity and respect. Staff were highly motivated and passionate about the care they delivered.

  • There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse.

  • Treatment was planned and delivered in line with national guidelines and best practice recommendations

  • Local and national audits of clinical outcomes were undertaken and quality improvements projects were implemented in order

  • It was easy for people to complain or raise a concern and they were treated compassionately when they did so.

  • There was a clear statement of vision and values, driven by quality and safety. Leaders at every level prioritised safe, high quality, compassionate care.

  • The trust had made end of life care one of its priorities in 2015/2016.

We saw several areas of outstanding practice including:

  • The trust had rolled out the Swan scheme across the trust that included a Swan bereavement suite, Swan rooms, boxes, bags and resource files for staff.

  • The palliative care team had developed a fast track checklist to provide guidance to ward staff on what to consider when discharging an end of life care patient.

  • Virginia Mason Institute (VMI) designed and developed its systems to become widely regarded as one of the safest hospitals in the world. The trust embraced these methodologies and in partnership with VMI, they have developed new initiatives within the hospital. They used the model to create the transforming care institute (TCI). TCI wants an effective approach to transforming healthcare by coachingteams and facilitating continuous improvement.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must ensure ED meets the Department of Health’s target of discharging, admitting or transferring 95% of its patients with four hours of their arrival in the department.

  • The trust must ensure all patients brought in by ambulance are promptly assessed and triaged by a registered nurse.

  • The trust must ensure a suitably qualified member of staff triages all patients, face to face, on their arrival in ED by ambulance.

  • The trust must ensure that it meets the referral to treatment time (RTT) for admitted pathways for surgery.

  • The trust must ensure there are sufficient nursing staff on duty to provide safe care for patients. A patient acuity tool should be used to assess the staffing numbers required for the dependency of the patients

  • The trust must review its medical staffing to ensure sufficient cover is provided to keep patients safe at all times.

  • The trust must ensure that all staff have an understanding of how to assess mental capacity under the Mental Capacity Act 2005 and that assessments are completed, when required.

  • The trust must ensure the application of the World Health Organisation’s (WHO) ‘five steps to safer surgery’ checklist is improved in theatres

  • The trust must ensure that up to date safety thermometer information is displayed on all wards

In addition the trust should:

  • The trust should ensure all staff received an annual appraisal.

  • The trust should consider using the maternity specific safety thermometer to measure compliance with safe quality care.

  • The trust must ensure they are preventing, detecting and controlling the spread of infections, associated in the mortuary department by ensuring surgical instruments are decontaminated to a high level and there are arrangements in place for regular deep cleaning.

Professor Sir Mike Richards

Chief Inspector of Hospitals

14-16 and 27 October 2014

During a routine inspection

Shrewsbury and Telford Hospital NHS Trust is the main provider of district general hospital services for nearly half a million people in Shropshire, Telford & Wrekin and mid Wales; 90% of the area covered by the trust is rural. There are two main locations, Royal Shrewsbury Hospital in Shrewsbury and Princess Royal Hospital in Telford. The trust also provides a number of services at Ludlow, Bridgnorth and Oswestry Community Hospitals.

Royal Shrewsbury Hospital was formed in 1979 after a number of hospitals in the town were closed or merged. The hospital provides a wide range of acute hospital services, including accident and emergency, outpatients, diagnostics, inpatient medical care and critical care. The hospital is also the main centre for acute and emergency surgery, and has a trauma unit that is part of the region-wide network. It is the main centre for oncology and haematology.

We carried out this comprehensive inspection because the trust had been flagged as a potential risk on CQC’s intelligent monitoring system. The inspection took place between 14 and 16 October 2014, with an unannounced inspection on 27 October.

Overall, this trust requires improvement. We found that services for children and young people, maternity and gynaecology, and outpatients were good. Urgent and emergency care, critical care, surgery, medicine and end of life care services required some improvements to ensure a good service was provided to patients. Caring for patients was good, but requires improvement in providing safe care, effective care, being responsive to patients’ needs and being well-led in some areas.

Our key findings were as follows:

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • The hospital was visibly clean and well maintained. Infection control rates in the hospital were lower when compared with those of other hospitals.
  • Patients’ experiences of care was good and the NHS Friends and Family test was in line with the national average for most inpatient wards, but was better than the national average for A&E.
  • The trust had recently opened the Shropshire Women’s and Children’s Centre at the Princess Royal site, and all consultant-led maternity services and inpatient paediatrics had moved across from the Royal Shrewsbury site. We found that this had had a positive impact on these services.
  • The trust has consistently not met the national target for treating 95% of patients attending A&E within four hours. At Royal Shrewsbury Hospital some improvements were also needed in the safe, effective and well led domains in A&E.
  • There was some good care delivered in the medical wards, but high staff vacancies and heavy reliance on bank and agency staff was putting considerable pressure on the existing staff.
  • We were concerned about ward 31 at Royal Shrewsbury Hospital, which was being used for day surgery patients while the purpose-built day surgery unit was being used for inpatients. The heating had not been switched on and there was no emergency call bell and staffing on this ward was a concern. Although the trust addressed these issues immediately when we brought them to their attention, this arrangement does not provide day-case patients with an effective service.
  • The hospital was not meeting the Core Standards for Intensive Care Units. We were concerned about nurse staffing levels and asked the trust to look at the situation immediately. During our unannounced inspection we were pleased to see the trust had responded.
  • The trust had recognised that end of life care needed to be improved and had begun working towards this, but we found much more progress was needed. We were concerned about the safety and effectiveness of the mortuary arrangements at Royal Shrewsbury Hospital in that the maintenance of this area was poor and it could not cope with the current demands placed on the service.

We saw several areas of outstanding practice, including:

  • The trust had good safeguarding procedures in place. The safeguarding team had links in every department where children were seen, with safeguarding information shared across the trust.
  • The trust had appointed an Independent Domestic Violence Advisor. The post had been supported through funding from the Police Crime Commissioner because of the excellent outcomes for people recorded by the trust. Referrals from the trust to the Multi Agency Risk Assessment Conference had been endorsed as excellent practice by Coordinated Action against Domestic Abuse (CAADA). CAADA a national charity supporting a multi-agency and risk-led response to domestic abuse.

We raised some of the urgent issues at the time of our inspection and the trust has taken action to address the equipment staffing needs within accident and emergency and critical care areas.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must review the levels of nursing staff across A&E critical care and end of life services to ensure they are safe and meet the requirements of the service.

  • Ensure that all staff are consistently reporting incidents and that staff receive feedback on all incidents raised so that further service development and learning can take place.

  • Ensure that staff are able to access mandatory training in all areas.
  • Ensure that accident and emergency and all surgical wards are able to access all the necessary equipment to provide safe and effective care.
  • Review pathways of care for patients in surgery to ensure they reflect current good practice guidelines and recommendations.
  • Ensure that mortuary services are safe through maintenance and security of this area.

There were also areas of practice where the trust should take action:

  • Review the availability of support staff across the seven-day week to improve outcomes for patients.
  • Review the achievements and actions taken to address the targets set nationally within A&E and across audits in medicine and in end of life care.
  • Review the specific equipment required to support an effective service for those people living with dementia.
  • Review medicines storage in surgery.
  • Review the capacity and flow within surgery and critical care to reduce waiting times and improve services to patients.
  • Review the provision of the end of life service to ensure that patients can access this service throughout the week.
  • Review the communication between senior managers and staff to ensure that initiatives and issues are captured.

Professor Sir Mike Richards

Chief Inspector of Hospitals

23 October 2013

During a routine inspection

The unannounced inspection was carried out by a team of five inspectors in addition to a specialist advisor and an Expert by Experience. We visited six wards where concerns had been raised through a variety of sources. Concerns were mainly around people's care, treatment and involvement and the lack of respect for privacy and dignity. People had also raised concerns in relation to how the trust had managed their complaints.

We spoke with patients and staff on all of the wards we visited and spent time observing how care and support was delivered. Our findings were very mixed with some marked differences between wards. There were differences in leadership and therefore effectiveness of systems and processes. We identified a range of concerns about consultation and involvement of patients, documentation of care planning and evaluation and key issues such as 'do not attempt resuscitation' (DNAR) orders.

Prior to our inspection the trust had acknowledged that capacity pressures across the hospital were impacting on people's experiences. They were actively addressing the challenges with health and social care partners. There was also recognition of the issues we identified during our inspection and action was being taken. A member of staff told us that increased admissions had resulted in 'huge pressures placed on the workforce'.

Overall patients described very positive experiences of their care and treatment. Comments included, 'I couldn't be treated any better if I was the King' and, 'The care from the doctors is very good and the nurses are excellent'. Most patients we spoke with told us that staff respected their privacy and dignity. Other patients commented that improvements were needed in how staff involved them in discussions and decisions about their care and treatment, for example their diagnosis, progress and discharge arrangements.

Patients we spoke with were not aware of how to make a formal complaint, although they told us they had not had cause to complain. We found information about complaints was not readily accessible for patients and their representatives. We saw the trust had responded to complaints but letters did not contain information for people on what to do if they were unsatisfied with the response provided by the trust. We found the trust had started to redress the identified backlog of complaints and the shortfalls in processes and acknowledged it was very much 'work in progress'.

During a check to make sure that the improvements required had been made

At our last inspection of the hospital we found that assessments, care plans and risk assessments had not been individualised or comprehensive which may have impacted on people's needs being met appropriately and effectively. We have reviewed the evidence given to us by the Trust who confirmed they are now compliant with this outcome.

16 August 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to be a patient in Royal Shrewsbury Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by a second CQC inspector, practising professional and an expert by experience, who has personal experience of using or caring for someone who uses this type of service.

We visited two wards providing adult inpatient care across the hospital. We spoke with nine patients who were receiving a service, two relatives and 10 staff from different disciplines. Patients we spoke with shared positive experiences about the care they received and how they were treated. They told us staff were respectful, promoted their privacy and dignity and kept them well informed about their care and treatment.

Patients were complimentary about the meals and food choices available. They told us their meals were served hot, were appetising and well presented. Where patients required assistance with eating, we saw staff provide support discreetly and respectfully. Patients who required specific meals to meet their dietary needs told us they were provided with the 'right' food.

Patients told us they were well cared for and said they felt safe. They described staff as competent and caring. One patient said, 'Everyone is wonderful here. They treat you properly and are very respectful.' Patients told us they were confident in raising any concerns with the staff.

Patients considered there was generally enough staff on duty to meet their needs. All but one person told us that staff attended to their call bells in a timely manner. One patient commented, 'The staff are rushed off their feet here but I'm not kept waiting'. Another patient said, 'The staff know what they are doing'. Staff were confident that numbers and skill mix could be changed in order to meet any changing circumstances of patient care.

Patients told us staff regularly spoke with them prior to completing their records. We saw evidence of good incident reporting processes in place. However, the current system for recording patient information was not integrated or unified. The trust had already identified this as an area requiring improvement.

11 October 2011

During a routine inspection

The inspection was unannounced and consisted of a team of three inspectors in the morning and four inspectors in the afternoon. We visited four wards providing adult inpatient care across the hospital. We spoke with 38 people who were receiving a service, three representatives and 10 staff from different disciplines. Most people we spoke with shared positive experiences about the care, treatment and support they had received. They said they were treated with dignity and respect; that staff asked before helping them with personal care tasks and explained what they were doing when carrying out tests or procedures. They told us staff responded to their needs in a timely manner most of the time.

Most people told us they were consulted about their care and treatment. Although one person told us that they had waited all day for an operation only to be told by a Housekeeper that their operation had been cancelled and served a meal they disliked. We saw a person being discharged and observed positive interaction by a member of staff wishing them a safe onward journey.

Overall we found that staff had a good knowledge of people's needs. However we found that assessments, care plans and risk assessments were not individualised or comprehensive. Most people we spoke with said that their needs were being met. Although we did not find that outcomes for people were poor, we did find that care plans and risk assessments were not being reviewed and monitored sufficiently to ensure appropriate treatment was consistent.

People told us the food was generally good with sufficient choice and support when needed. However, we observed one older person, who was a vegetarian, being assisted to eat a meat dish. A notice was displayed above their bed indicating their specific dietary preference, however there was nothing documented in their care plan in relation to their dietary requirements. We saw the staff member take swift action to rectify the situation.

People told us that they felt safe in the care of staff and that they had not observed any poor practice during their stay. Although not everyone had knowledge of the complaints procedure, they told us they would raise concerns with the staff on duty. People who had raised concerns told us these had been dealt with in a timely manner.

Most people told us there were sufficient staff and skill mix to meet their individual needs although at times staff were 'stretched' and that this can impact on their care and treatment. People said staff were competent, attentive and caring.

29 March 2011

During a themed inspection looking at Dignity and Nutrition

Overall people told us that staff involve them in their care, treatment and support and that their privacy and dignity is respected. Most people told us that staff call them by their preferred form of address and respond to their needs quickly. They said that staff are kind and explain what they are doing. One person said, 'The staff are very careful how they handle me' another person said, 'One time I was being washed and they left me in the middle of my wash to attend to someone else. I was left about half an hour'.

People said they are offered a good choice of food but this is not always the option they actually receive. Most people told us they felt their nutritional needs and dietary preferences were well met. All but one person we spoke with was happy with the food portions and how their food was presented. One person said, 'I'm quite impressed with the food and the care is fantastic. The staff are very good at offering lots of drinks. They really are doing it very well'.