Third of wards at Western General 'short of nurses'

The hospital uses a three-level risk score - green, amber, and red - to monitor staffing risks in real-time based on matching the availability of nurses and midwives to patients, according to their needs and complexity.

Green means "business as usual"; amber indicates that action is needed; and red requires escalation to senior leaders.

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Inspectors noted that "in many cases" the response to an amber alert would be to "move staff to other clinical areas to improve the skill mix or number of staff available" but that "in exceptional cases, some patients would be moved to a ward with safer staffing levels if this was what was required to provide the right care for the patient".

However, they added that during the period of inspection "all patients were cared for within the correct speciality for their condition".

Inspectors praised the "open and transparent" system, recommending that it be extended to other clinical staff groups.

Overall, they found that patients "appeared to be treated with kindness and compassion" despite the pressures on staff, with the intensive care and high dependency units in particular having set up a projector screen to allow patients who were well enough to watch sporting events and music festivals.

"This demonstrated a commitment from the staff to enhance the patient experience of care, even when under pressure," said inspectors.

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However, the report noted that there were impacts on care as a result of staff shortages, including one patient whose skin care needs were not being met despite documentation indicating that "there was already concern about their skin".

Inspectors said they were told by staff that "this was on their list of tasks [but] they had not yet been able to get to this due to the lack of staff and level of care needs on the ward".

On another ward, where a senior charge nurse role was vacant, the lack of leadership "was impacting on the team".

The report states: "Staff also told us the effect of staff shortages on stress levels and morale amongst the team and they were concerned about the impact the situation had on delivering high-quality patient care.

"For example, prioritising and identifying those who need support at mealtimes, response times for those with a falls alarm and managing break times effectively.

"We were concerned to learn that staff felt the current pressures meant they did not have time to report these safety issues through the incident reporting system."

At the time of the inspection, bed shortages meant there were more than 10 patients who had been waiting over 12 hours to be admitted from its medical assessment, surgical admission or same day emergency care (SDEC) units, with no medical or receiving beds available at the start of the day for any new admissions.

Inspectors also raised concerns around Covid infection controls after seeing that some staff members were wrongly moving between areas while "wearing face masks inappropriately, such as under their chin or secured on their arm".

The report also flagged potential infection risks at the Western General's SDEC, which is used to alleviate demand on emergency departments within NHS Lothian by dealing with patients who are less likely to require admission. It is open seven days a week from 8am to 7pm.

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At the time of the inspection, the SDEC was the only remaining clinical area still in use in one of the hospital's older buildings.

The department was described as being in "a poor state of repair with damaged woodwork and hazardous dips and cracks in floor coverings" which "would impede the ability to effectively clean the flooring".

Inspectors added that showers, sinks, and toilets were not being flushed as regularly as they should be to prevent the spread of waterborne pathogens.

Furthermore, they added that "the infection prevention and control team had not conducted any audits or walk rounds of the area since 2019".

By the time of an unannounced follow-up inspection on September 6, the SDEC had relocated to a new area of the hospital ahead of its planned move to a new purpose-built facility in late 2023.

The report noted that NHS Lothian "planned to evaluate the option of continuing to provide the service from the new location, including reviewing the costs for improvements required for SDEC to return to the previous location" and that the "infrequently used water outlets in the old SDEC building were now being flushed by the estates department".

Donna Maclean, head of service for HIS, said: “At the time of inspection, Western General Hospital was experiencing a significant range of pressures including increased hospital admissions, increased waiting times in admission units and reduced staff availability.

"Despite this, we observed staff in clinical areas working hard to ensure the patients’ care needs were met. There was good leadership directing and supporting the staff teams in many of the areas inspected.

“We carried out a return visit to follow up initial concerns about the condition and maintenance of the care environment within same day emergency care.

"On our return visit, we were assured the service had been relocated to an area with an improved environment.”

Dr Tracey Gillies, Medical Director, NHS Lothian said, “Across the NHS, services and staff are under considerable pressure and NHS Lothian is no exception to this.

"Despite this, it is pleasing to see many areas of good practice have been recognised within this report particularly around patient care.

"Teams at the Western General Hospital were praised for how patients are treated with kindness and compassion, with the report noting how staff often go above and beyond to support and improve the care experience.

“Across NHS Lothian, we have comprehensive processes in place to respond to the unprecedented pressure our services continue to face.

"Again, it is pleasing to see these formally recognised and acknowledged, with the report noting positive multi-disciplinary engagement, open and honest systems for reporting risk and good visibility of senior leadership – all of which help to support the delivery of safe and effective patient care.

“We note that there were some areas that the inspectors felt could be improved and an action plan has been developed to address these.”