The purpose of our Quality Insight bulletin is to highlight the key findings from the work we have undertaken, including engagement with healthcare providers and other intelligence that we hold. The aim is to support improvement within healthcare services by sharing our findings, with a focus on good practice and learning, so that services can take note and adapt accordingly through this unprecedented and challenging time.
These findings are primarily based on our adapted approach to assurance, through our HIW Quality Checks, and capture positive themes, good practice and emerging risks. Our Quality Checks are conducted entirely offsite and focus on three key areas:
- Infection prevention and control
- Governance (specifically around staffing)
- Environment of care.
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We carried out 43 Quality Checks from August to October 2020, which included:
- 19 NHS Hospitals
- 5 Independent Hospitals
- 8 NHS Mental Health settings
- 9 Independent Mental Health settings, and
- 2 GP Practices
Although our routine programme of inspections was paused at the onset of the COVID-19 pandemic, we have continued to conduct some onsite inspections in response to concerns or intelligence indicating that there may be a high risk to patient safety. However, this has only happened when other means of gaining assurance and evidence have been exhausted, and where we have conducted a full risk assessment to ensure the safety of our staff.
During this period, and as a result of serious concerns reported to HIW, we conducted three onsite inspections. These took place at two dental practices and one independent mental health setting. We also completed an onsite inspection of a field hospital to check the arrangements for patient care. The reports can be found on our website.
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Health and care services across Wales have had to rise to meet the challenges of a global pandemic, COVID-19. The pandemic has introduced unique and unprecedented pressures on the system that will continue through the winter months. Through our work and intelligence, we have found many examples that highlight the outstanding efforts of staff whilst providing services to patients and the public. As such we would particularly like to commend the commitment and flexibility of all staff working within healthcare services, who have worked tirelessly to help keep patients and their colleagues safe.
Staff have described how new approaches have been implemented, such as the provision of electronic devices for patients to stay in touch with family and friends, and enhanced arrangements to strengthen infection prevention and control to minimise the risk of transmission of the COVID-19 virus. In addition, department managers, senior managers and executive teams have told us throughout, of their appreciation and pride for their teams. We cannot, however, underestimate the levels of fatigue, stress or anxiety of those working in such difficult times, and the impact this has on healthcare services. Therefore robust arrangements to support the workforce are critical to the viability of services as the pandemic continues.
Environment
A significant amount of time and effort has been spent on redesigning hospital wards and unit environments to help reduce the transmission of COVID-19 and to keep staff and patients safe. However, we found at times that action had not been taken following issues identified via routine environmental risk assessments and audits. This is an important issue for departments and health boards to consider, to ensure that actions are completed in a timely manner to maintain the health and safety of staff and patients. This is highlighted later with other examples, within the Infection Prevention and Control section.
Innovation has been demonstrated, with some health boards ensuring that patients are provided with personal electronic devices to help maintain contact with friends and family during their time in hospital. This has been essential to help minimise the distress and isolation that patients or their families may experience. Departments and health boards should continue to evaluate how restrictions on visiting may impact on the opportunity for family members or carers to provide support, or to be involved in discussions or decisions regarding the care of patients. To maintain effective support and communication in relation to patient care and both their and their family’s well-being, it is important that appropriate mechanisms remain in place to facilitate this. Similarly, there should be clear arrangements for families and carers to keep in touch with departments, particularly where patients are unable to have any contact with family members, without proactive help and support.
Infection Prevention and Control (IPC)
Appropriate and effective IPC arrangements continue to be of paramount importance during the pandemic. Over the past months several hospital sites have been impacted by outbreaks of COVID-19. It is essential that outbreaks are managed effectively when they occur, and actions are taken to mitigate the risk of further transmissions or outbreaks. We have noted that appropriate action has generally been taken following COVID-19 outbreaks in hospitals, and lessons learnt have been shared with staff and across organisations. This is essential to help prevent the spread of COVID-19 in hospital settings (nosocomial transmission).
It was positive to find that in line with Public Health guidelines, enhanced arrangements have been introduced across Wales, aimed at reducing nosocomial transmission. However, in some areas, IPC audits were out of date or had been completed but with minimal learning from the results. This is similar to the finding for environmental risk assessments, and reinforces the message that all departments should ensure that risk management and audit processes are robust at all times.
Arrangements are in place to ensure staff can access appropriate Personal Protective Equipment (PPE), and training has been widely provided on its correct use. However, we are concerned that some staff working in higher risk areas who require a higher level of PPE, have experienced skin damage, dry eye syndrome and fatigue. We are aware that some health boards provide fast track services to dermatology and ophthalmology for those who require this support, and health boards should ensure this is consistent across Wales.
Processes are in place in most areas to assess the risk of deploying staff who are clinically more vulnerable or at a higher risk from COVID-19, which includes consideration to Black, Asian and Minority Ethnic groups. However, we escalated concerns where applicable, following Quality Checks in which we identified risk assessments had not been completed. The absence of risk assessments can compromise the health and safety of staff, and it is essential that robust processes are in place in all departments, to ensure all high risk staff are identified promptly.
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Governance
An important factor requiring consideration during the pandemic relates to staff well-being. It is clear that staff have been working in a hugely challenging environment these past months. Consequently we are concerned that staff working in healthcare may be suffering significant anxiety and fatigue at this time. Across Wales, we have noted the implementation of positive interventions to help support the well-being and mental health of staff. It is vital that all departments continue to ensure they do all they can to support their workforce through these very challenging times.
It was positive to find that specific training on COVID-19 has been provided for staff in all settings. However, as might be expected, the lack of opportunities for face to face training and increased work pressures has significantly impacted on the completion of mandatory training in some departments. This was more prevalent during the early stages of the pandemic, and throughout Wales we were told that the emphasis on e-learning has been promoted to help with compliance. Whilst dealing with the heightened workload associated with responding to the pandemic, completion of mandatory training requires close monitoring. Failure to ensure that staff training is up to date may potentially result in unsafe practice and increased risk to patients, so it is important that all health boards strive to ensure their workforce receives timely training appropriate to their roles. This also relates to the use of temporary staff, who may be unfamiliar with a particular environment of care. Departments should ensure robust processes are in place for familiarisation and induction of temporary staff in new areas, and to provide appropriate training where applicable.
Positive steps have been taken to meet the need for more frequent communication during the pandemic, to ensure staff are aware of changing guidance. This includes the use of daily staff huddles, which have replaced monthly meetings, as an agile approach to keep staff up to date with accurate advice and guidance. The need for ongoing frequent communication is essential as the COVID-19 pandemic evolves, particularly where there is a heavy reliance on temporary staffing arrangements, including where care is being managed in reconfigured or temporary settings.
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Environment
Throughout the pandemic, independent hospitals have been utilised as COVID-19 free environments as a means of providing urgent scheduled care, such as surgery on behalf of the NHS. This support has been essential and we found clear and focused efforts have been made to enable independent hospitals to remain open. These arrangements include robust environmental risk assessments, pre-admission COVID-19 testing and the requirement for patients to self-isolate at home prior to admission. On arrival to the hospitals, new front of house triage and testing processes are in place, which aim to detect any patients with potential COVID-19 symptoms.
We are aware of new initiatives that have been introduced to help keep patients safe during the COVID-19 pandemic. This includes one provider implementing new colour coded ‘patient pathways’ to help guide patients through the hospital. Under this model, the pathway the patient takes is dependent on any requirements for COVID-19 testing and self-isolation before the appointment, and the reason for the visit. We consider this a positive initiative, as it defines an appropriate healthcare journey for patients and in particular those who are clinically vulnerable to help reduce the risk of potential infection.
Infection Prevention and Control (IPC)
Appropriate and effective IPC arrangements remain a priority and are essential during the pandemic. At the time of writing this Quality Insight bulletin we have not received reports of any incidents relating to patients contracting COVID-19 while in an independent hospital setting.
It was positive to find that in line with Public Health guidelines, enhanced arrangements have been introduced across Wales, aimed at reducing nosocomial transmission. However, we did find one ward where an IPC audit had not been completed for three months. This is a concern, and it important that providers maintain focus in this area.
Arrangements are in place to ensure staff can access appropriate Personal Protective Equipment (PPE) and training has been provided on its correct use. This includes refresher training for staff who return to work after being furloughed. We are also aware of new initiatives which have been introduced in independent hospitals to help reduce the risk of nosocomial transmission. One such initiative was making additional scrubs available for staff, which enables uniforms to be washed on site instead of staff taking them home to clean.
Through our notifiable events process, we identified one independent hospital where a small number of staff had tested positive for COVID-19. We have since received assurance from the service that the incident has been investigated and responded to appropriately, with additional training being provided to all staff. It is essential that all staff are frequently reminded about the correct use of PPE, and the need to comply with social distancing guidance when interacting with each other socially.
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Governance
The consideration of staff well-being during the pandemic is essential. It is clear that staff have been working in hugely challenging environments since the start of the pandemic. As with all frontline staff, those within independent healthcare settings can present with fatigue, anxiety or stress, and employers should ensure their staff are appropriate assessed and monitored. We have noted the positive implementation of supportive interventions, to help maintain the well-being and mental health of staff. The take up of these interventions should be closely monitored, to ensure staff are fully supported through these challenging times.
It was positive to find that specific training on COVID-19 has been provided to staff in all settings. Completion of mandatory training has also remained high throughout the pandemic, with e-learning replacing the traditional face to face and classroom based training. In addition, training compliance is being closely monitored, along with training for COVID-19 arrangements.
Independent hospitals in Wales do not provide emergency care and the pathway is based on outpatient services and scheduled care. As a result, healthcare providers are more able to plan staffing levels in advance of hospital appointments or admissions. Consequently we found that overall staffing levels have remained stable throughout the pandemic. Hospital managers told us how they held early conversations with staff to support them to feel confident in the workplace; these included discussions with staff who may need to shield or self-isolate.
Keeping staff up to date with changing guidance and operating procedures has been a key challenge for all healthcare providers during the pandemic. Hospital managers have recognised this and described the new arrangements in place to keep staff updated on the rapidly changing guidance and advice for COVID-19. They highlighted to us that more frequent communication was essential, and this had been addressed through virtual team meetings and video calls to maintain frequent engagement with staff. It was positive to find that such communication has also been extended to all staff working on the site, including those from the NHS. As the pandemic progresses, it is essential that independent providers maintain frequent communication and guidance to all staff.
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Environment
Every effort has been made to make changes to the care environment in mental health settings, to help minimise the transmission of COVID-19 and keep patients safe. In instances where individual wards were being considered as household bubbles, changes had been implemented to increase social distancing between patients within the ward bubble. For example, many hospitals had introduced additional meal times, so that less people were present dining meal times. We were also told that staggered start times had been introduced for staff, to avoid large numbers of staff congregating in the entrance areas.
Patients have been able to maintain contact with healthcare professionals through virtual means, including participation in therapy sessions and to access advocacy services. Additional electronic devices have been purchased to help patients stay in contact with family and friends. This has been essential to help minimise the distress and isolation that patients or their families may experience. Departments should continue to evaluate how the restrictions on visiting may impact on the patient and on the opportunity for family members or carers to provide support, or to be involved in discussions or decisions regarding the care of patients. To maintain effective support and communication in relation to patient care, it is important that appropriate mechanisms remain in place to facilitate this. Similarly, there should be clear arrangements for families and carers to keep in touch with departments, particularly where patients are unable to have any contact with family members, without proactive help and support.
The pandemic has unfortunately resulted in some patients feeling scared and isolated due to the restrictions on visitation and day leave, thus increasing their anxiety levels or affecting their progress or recovery. We found that positive action has been taken to address this issue, through the introduction of additional activities and therapy for patients to keep them occupied, such as more gardening activities and using the hospital grounds for walking. We consider these initiatives to be essential during the pandemic to avoid an increase in challenging behaviour and the potential for self-harm as a result of feeling isolated, fearful or bored.
We are disappointed to have identified inconsistent practice in relation to ligature risk assessment in some settings. This includes poor levels of detail in remedial and mitigating actions, and incomplete action where this was necessary. In addition, we were presented with ligature risk assessments that were over 12 months old, without review, which is a significant concern particularly in relation to patients at a higher risk of self-harm. It is essential that robust processes are in place, to ensure ligature risk assessments are completed more frequently.
Infection Prevention and Control (IPC)
Appropriate and effective IPC arrangements continue to be of paramount importance during the pandemic. During the first wave of the pandemic it was positive to note that very few COVID-19 incidents were identified in independent mental health and learning disability hospitals. Where we were informed of positive cases, these were single isolated cases, and many individuals with symptoms consistent with COVID-19, were subsequently confirmed to have tested negative for the virus. However, during the second wave, there has been a significant increase in the number of positive COVID-19 cases in independent mental health and learning disability hospitals.
A potential contributing factor for the increased incidence during the second phase, is the absence of a regular testing regime for staff and patients, for early detection in asymptomatic people. Instead, staff and patients are only tested after a number of cases occur in an independent hospital, and the residential services incident management arrangements is invoked. The arrangements include weekly testing of staff and patients until such time that no positive test results are returned, and no further positive cases are identified for 28 days. This means that an outbreak must occur before testing is provided. Where incident management arrangements have been activated, the testing has identified significant numbers of asymptomatic members of staff as COVID-19 positive, who without testing, would have continued to work in the hospital with the potential to transmit the virus throughout the patient and staff groups. Welsh Government should consider implementing a regular testing regime in these hospitals as a protective measure for all staff and patients.
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Governance
The consideration of staff well-being during the pandemic is essential. It is clear that staff have been working in hugely challenging environments since the start of the pandemic. As with all frontline staff, those within independent healthcare settings can present with fatigue, anxiety or stress, and employers should ensure their staff are appropriate assessed and monitored. We have noted the positive implementation of supportive interventions, to help maintain the well-being and mental health of staff. The take up of these interventions should be closely monitored, to ensure staff are fully supported through these challenging times.
Through our quality checks we were able to confirm that regular multidisciplinary team meetings have continued throughout the pandemic. These are essential to ensure patients are cared for and managed appropriately and effectively. In addition, emergency appointments with other key mental health professionals have been available to maintain appropriate care.
It was positive to find that specific training on COVID-19 has been provided to staff in all settings. However, the inability to attend face to face training, and increased work pressures has significantly impacted on mandatory training compliance in some areas. This was more prevalent during the early stages of the pandemic, and has been addressed by the promotion of online training options. However, we are concerned that some key areas of mandatory training, such as physical intervention and restraint, which is required at times to de-escalate challenging behaviour cannot be effectively delivered online. This is an important area for providers to consider, along with robust risk assessments, particularly in environments with high incidences of challenging behaviours.
Patients have a right to have their detention reviewed by the Mental Health Review Tribunal for Wales. All hospitals were able to demonstrate that this right had been maintained, with the majority of tribunal meetings taking place on time, through virtual means. Whilst virtual meetings have enabled this type of meeting to take place, we would encourage hospital managers to obtain feedback from patients on whether they felt as engaged and enabled to participate appropriately, as they may have previously. Patients will also be best placed to identify how their experience could have been improved.
Keeping staff up to date with changing guidance and operating procedures has been a key challenge for all healthcare providers during the pandemic. It has also been essential to ensure patients are communicated with effectively, to help them understand the changing restrictions placed upon them, as a result of COVID-19. We found that hospital managers had approached this in a variety of ways, but the most important factor was an increase in the frequency of direct communication, through updates provided at daily staff meetings and patient briefings. The need for ongoing frequent communication with patients and staff is essential as the COVID-19 pandemic evolves.
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Whilst we conducted only two quality checks of GP practices, we need to highlight concerns regarding the use of remote consultations, and the risk that some patients may not be able to access services due to technical or logistical challenges.
Although there are many benefits to remote consultations, there is a clear risk that some cohorts of patients may be digitally excluded, and are unable to conduct a video call. It is therefore important that relevant patient groups are still able to safely access in person appointments.
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At the time of writing this Quality Insight bulletin, we have undertaken two onsite dental inspections during the COVID-19 pandemic. These were risk based inspections as a result of concerns that standard operating procedures were not being followed in line with Public Health guidance. Our inspections in the main have validated these concerns. The key findings are as follows:
- A dental surgery had not been de-cluttered and contained items that could not be cleaned effectively
- PPE not being changed post-Aerosol Generating Procedure (AGP), and before cleaning commences
- Insufficient evidence of fallow time compliance between procedures, with no record of the time at which the AGP element of the treatment had finished
- No expert verification of air changes per hour
- The strength of the detergent being used was not in accordance with recommendations
- Use of purifiers designed for domestic rather than commercial use, with no evidence to support the assertion that these reduce the presence of the COVID-19 virus.
This final point is very concerning, as we are aware that many practices are using air purifiers in the absence of mechanical ventilation. We would urge all practices to check the manufacturer’s guidance and instructions, and or contact the manufacturer to confirm if the device is appropriate for use in a dental surgery.
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