Conditions have been imposed by the care watchdog on the Royal Stoke University Hospital after an unannounced inspection of services.
The Care Quality Commission (CQC) raised a number of issues with the Emergency Department.
It includes time taken for clinical assessment on arrival and protection of rights of patients detained under the Mental Health Act.
And two weeks after the visit last month a formal notice was issued to University Hospitals of North Midlands (UHNM) NHS Trust.
This week the trust board heard that action has already been taken to address the concerns raised. UHNM is providing weekly updates to the CQC of its progress and an action plan has been drawn up.
A report by UHNM chief executive Tracy Bullock presented to the board meeting said: “The CQC identified a number of areas of concern as well as many areas of good practice and fed these back to the Trust on an informal basis. A more formal letter was then issued and the trust was asked to provide further assurance in relation to concerns raised.
“Although the CQC were reassured regarding the majority of their initial concerns, on June 19 they issued a notice of decision to impose conditions on our registration as a service provider in respect of regulated activities. This was issued formally under Section 31 of the Health and Social Care Act in relation to observations within the Emergency Department (ED) regarding appropriate and timely clinical assessment on arrival and actions taken to ensure that patients detained under the Mental Health Act would have their rights protected.
“Given the notable achievements in our ED since the last CQC inspection and a demonstrable trust-wide commitment to ensuring the parity of esteem for patients with mental health issues, we are disappointed that such action was required and we are fully committed to working closely with the CQC to ensure that they have the assurance they need in these important areas.
“The CQC revisited ED on 28 June where some improvement was noted, although there remained areas where non-compliance had been noted.”
The concerns about compliance with the Mental Health Act related to one patient, the board was told.
Mrs Bullock said: “The patient hadn’t had the appropriate paperwork completed that came with him. Issues they raised within the ED were particularly around ambulance arrivals and the start of triaging within 15 minutes.”
Board chairman David Wakefield asked if patients were safe in the ED and was told they were.
The CQC also visited areas including maternity, outpatients and children’s departments during the three-day inspection in early June.
Mrs Bullock’s report added: “The trust has received a formal response regarding maternity and outpatients. With regards to maternity the CQC fed back that they were very impressed by the effective systems and processes and evidence base culture of learning and sharing with the wider trust and outside of the organisation.
“They also commented on the positive culture and morale. However they commented that there was not enough capacity to meet the increasing demand for elective C-sections and pain scores were not always documented.
“With regards to outpatients, the CQC commented that all observed patient care was good, staff were compassionate and caring and always introduced themselves. However they commented that local recording of statutory and mandatory training and appraisal did not reflect the corporate figures.
“A formal report and trust rating will be published by CQC in the autumn.”