AN EMERGENCY department under a special measures health board remains a "service requiring significant improvement."

Healthcare Inspectorate Wales (HIW) visited Glan Clwyd Hospital's A&E in Bodelwyddan for a third time in November 2022. On day two of their visit, inspectors ended up supporting a patient who was unwell and needed help - "No staff could be located."

In their latest report, HIW highlighted staff were working "tirelessly" but inspectors once again found an "incredibly busy department, struggling with shortages of staff, high numbers of seriously unwell patients and a lack of space to treat them".

Inspectors stated: "Emergency Department (ED) staff were working tirelessly in this challenging environment to provide the best care that they could, but told inspectors they often felt unhappy, struggled with the workload and did not feel supported by health board senior leaders. They did, however, praise the managers who worked directly within the department, and we found that at this local level, both senior medical leadership and senior nursing leadership was supportive and visible.

"We did find evidence that there had been improvements to the overall standard of recording within patient notes.

"ED medical staff were recording interventions and actions clearly and they were easy to follow, nursing staff were recording their care and interventions in a similarly clear, improved way. This was a positive finding and indicated progress had been made in this area since our last inspection.

"The inspection identified that the staffing rota for the department was challenging to maintain, with a heavy reliance on using bank and agency staff to cover absences, alongside a difficulty in recruiting and retaining staff. Staff also raised concerns about the varied levels of staff experience available on shifts, including times when most staff were junior." 

On day two of the inspection, HIW noted that the department was "short of both nurses and healthcare assistants (HCAs)."

Inspectors commented: "Staff were moved to support the busiest areas of the unit, which meant the corridor area accommodating unwell patients was left unsupervised. During this time HIW inspectors had to support one patient who was unwell and needed help, but no staff could be located."

Inspectors found that efforts had been made to improve the arrangements for oversight and care provided to patients in the waiting room, including a registered nurse now allocated to cover patient arrival and waiting areas. When there was no nurse available, an HCA was assigned to this role.

Inspectors found that initial waiting times to see a doctor had improved since their last visit in May 2022, but these were still in the region of three hours.

The provision of timely care to patients within the department was again highlighted by inspectors as an area for improvement. There were significant delays in patients being triaged and this placed patients at significant risk of harm. These delays exceeded two hours at times and included patients with time critical conditions such as stroke and chest pain. This meant that treatments could not be offered within recognised critical intervention timescales.

The report added: "There was evidence that observations such as blood pressure checks, records of pulse and breathing rate on patients at risk of deterioration were not repeated at a frequency in line with national guidelines."

Issues also remained in relation to management of environmental risks within the department.

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Inspectors said: "There were medicines left unattended, out of date medication, unlocked cupboards containing sharp instruments easily accessible and doors between different areas of the department not secured. We also found empty food trays, used urine bottles and other clinical equipment not cleared away for long lengths of time."

A plan has been produced by Betsi Cadwaladr University Health Board (BCUHB), which was put into Special Measures for the second time on February 27, to address the wide range of improvements needed.

Alun Jones, chief executive of HIW, said: "This inspection found evidence of a department struggling to cope with the day-to-day demand of providing a safe service to patients. It has highlighted areas such as poor team working between the ED and other departments within the hospital which in turn is compounding nationally recognised challenges around patient flow.

"The health board will need to take strong and decisive action to tackle the issues identified in our inspection.

"We will continue to engage with the health board to ensure sustained action is taken in relation to our findings."

Dr Nick Lyons, executive medical director and interim deputy chief executive of BCUHB, said: “Firstly, I would like to apologise for the instances where patients did not receive the level of care they deserved. I note the inspection team’s comments surrounding improvements since the last report, but it is clear we still have some way to go in providing a service in our emergency department which is consistently good for every patient.

“It is true staff within the ED at Glan Clwyd Hospital have been under enormous strain for the past three years and this has increased since restrictions eased.

“Attempts to attract permanent members of staff to support the ED’s work continues, and another recruitment open day is planned within the next few weeks. However, the fragility in staffing and the volume of acutely unwell people we receive each day means we remain a service requiring significant improvement.

“The vast majority of our colleagues are a credit to our organisation and we value their hard work and professionalism. We will continue to strive to make sure they feel supported by colleagues in other specialties and their hospital management teams.

“I note with pride the inspection team’s comments about how hard our staff work and their commitment. I’m also pleased the majority of patients they spoke to are happy with the care they receive within the department.

“Record keeping has improved and the inspection team noted the commitment of our staff to give the level of care we would all want to see.

“Despite the issues raised in the report inspectors acknowledged progress has been made but we know this needs to accelerate.

“Our colleagues within ED, and in other areas of the hospital, are fully focused on driving this change forward and we are pleased to see the proportion of patients moving through the department within four hours continuing to rise.”