Ysbyty Glan Clwyd de-escalated from 'needs significant improvement' status but challenges remain
Carol Shillabeer, Chief Executive of Betsi Cadwaladr Heath Board
Healthcare Inspectorate Wales is de-escalating Ysbyty Glan Clwyd in Rhyl from it's 'needs significant improvement' status, following an unannounced follow-up inspection of the Emergency Department.
In May 2022, the department, run by Betsi Cadwaladr University Health Board, was designated as a Service Requiring Significant Improvement (SRSI).
A follow-up inspection in November 2022 found only minimal improvement and the designation remained in place.
But during the recent inspection over three consecutive days in April/May 2024 HIW say they "found a marked improvement within the areas of significant concern identified in 2022."
These areas included the timely escalation of patients with critical and high-risk conditions, and strengthened oversight of the waiting area compared to previous inspections.
Overall, inspectors highlighted an improved culture, an increasing in staffing levels and stronger leadership.
They say that because of these improvements, they are able to de-escalate the service.
Despite the de-escalation they say "several issues remain for the service which continues to operate in highly demanding and challenging conditions.
"Areas of concern included excessive waiting times, inadequate processes for issues with medication management, and insufficient checks of life-saving equipment.
"We noted that oversight of the unit’s waiting room had improved with patient emergencies escalated and well managed.
"Overall, the department was clean and tidy, with robust infection prevention and control measures in place; and general health and safety risks assessed.
"However, we were concerned that pressure and demand within the department was leading to an increased risk to patients. "
They identified a poor flow of patients from the point of admission to discharge as a continuing issue.
"During the inspection there were around 50 patients each day who were deemed well-enough to be discharged with the unit at full bed capacity.
"However, their discharge was delayed for various reasons such as waiting for further rehabilitation, a care package to be put in place or a placement in another care facility.
"Patients were waiting roughly four hours for treatment within the department, with just under a quarter of patients waiting over twelve hours before being seen."
Inspectors found that one patient was not seen by a doctor for over 10 hours with a suspected neck of femur fracture, and no record of pain relief.
They say some patients also told them they had waited up to 48 hours and had not been informed or updated on their care and treatment plans.
Inspectors saw evidence of strong staff communication during shift handovers, and good working relationships within the department and with ambulance staff. Inspectors witnessed positive staff to patient interactions, with staff treating patients with dignity and respect, despite challenging conditions.
Inspectors said immediate action should be taken in several areas including the checking of lifesaving equipment, the management of medications, and the procedures in place to conduct regular patient check-ups, assessments, and observations.
Inspectors were not assured that medication management processes were sufficiently robust and safe due to inaccuracies with administering medication, and the inadequate monitoring of patient conditions such as fluid intake for issuing cannulas.
They said "it was concerning to note that some patients, who needed either pressure area risk assessments, or falls risks assessments, didn’t receive these assessments until they had been in the department for over six hours.
"Consequently, adjustments were not immediately in place for those at risk due to mobility issues, or increased fragility.
"There were often delays in patients receiving treatment from specialist doctors, an area identified for improvement in the unit’s previous inspection.
"It was also concerning to find resuscitation equipment, such as a defibrillator in one room had not seen checked since early January 2024."
Inspectors found that only three in ten patients were triaged within the national recommended time limit of 15 minutes, with the average being approximately 58 minutes.
Improvements were also required to ensure that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) discussions are accurately recorded and readily available to staff.
A plan has been produced by the Health Board, which contains a comprehensive set of actions to address the wide range of further improvements needed.
Alun Jones, Chief Executive of Healthcare Inspectorate Wales, said "The pressure and demand on healthcare services continues to create significant challenges for the NHS.
"During this inspection we found staff working extremely hard in challenging conditions to provide patients with safe and effective care.
"It is reassuring to see improvements have been made since our previous inspections of the department, but further improvement is still needed.
"I hope this report will provide the health board with a clear understanding of the challenges being faced by the service and support the action they need to improve.
"We will be working with the health board to ensure these improvements are made and evidenced."
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