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Arrowe Park Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 March 2016

Arrowe Park Hospital is one of two hospital sites managed by Wirral University Teaching Hospitals NHS Foundation Trust. The hospital is the main site and provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, a neonatal unit, children and young people’s services, maternity and gynaecology services and a range of outpatient and diagnostic imaging services.

The hospital is located on the Wirral peninsula in the North West of England and serves the people of Wirral and neighbouring areas.

Wirral University Teaching Hospitals NHS Foundation Trust became a Foundation Trust on 1 July 2007. The trust provides services for around 400,000 people across Wirral, Ellesmere Port, Neston, North Wales and the wider North West footprint with 855 beds trust-wide, including 749 at Arrowe Park Hospital.

We previously inspected this hospital in May 2015 as part of a responsive unannounced inspection and found that there were shortages of nursing staff on some medical wards which we told the trust to address.

We carried out an announced inspection of Arrowe Park Hospital on 16 – 18 September 2015 as part of our comprehensive inspection of Wirral University Teaching Hospitals NHS Foundation Trust and we checked to make sure staffing levels had improved.

Overall, we rated Arrowe Park Hospital as ‘Requires Improvement’. We have judged the hospital as ‘good’ for caring. We found that services were provided by dedicated, caring staff and patients were treated with dignity and respect. However, improvements were needed to ensure that services were safe, effective, well led and responsive to people’s needs.

Our key findings were as follows:

Cleanliness and infection control

  • The trust had infection prevention and control policies in place which were accessible to staff.
  • Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures. However, in the critical care unit not all staff followed ‘bare below the elbows’ guidance and there was mixed levels of compliance with hand hygiene protocols.
  • ‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.
  • There had been no cases of methicillin resistant staphylococcus aureus (MRSA) bacteraemia infections or clostridium difficile infections identified in surgical services across the trust between March 2015 and August 2015. However, across the same period, medical care services reported 21 cases of clostridium difficile infections, two cases of MRSA and six cases of MSSA. The data could not be split so as to separate cases that specifically occurred at Arrowe Park Hospital.
  • According to the submitted and verified intensive care national audit and research centre data (ICNARC), the critical care unit performed as well and sometimes better than similar units for unit acquired MRSA and clostridium difficile infection rates.
  • Side rooms were used where possible as isolation rooms for patients at increased risk of cross infection. There was clear signage outside the rooms so that staff were aware of the increased precautions they must take when entering and leaving the room.
  • We observed that the disposal of sharps, such as needle sticks followed good practice guidance. Sharps containers were dated and signed upon assembling them and the temporary closure was used when sharps containers were not in use.
  • Patient-led assessments of the care environment (PLACE) audits for 2013 and 2014 scored higher than the national average for cleanliness across the trust, specific data for Arrowe Park Hospital was not available.

Nurse staffing

  • We previously inspected this hospital in May 2015 as part of a responsive unannounced inspection and found that there were shortages of nursing staff on some medical wards which we told the trust to address.
  • The trust had responded positively to our last inspection and had actively recruited nursing staff in a variety of ways to improve staffing levels. However, there were still staffing shortfalls across the hospital.
  • To attempt to address shortfalls in staffing, matrons met each day to discuss nurse staffing levels across the divisions to ensure that there was good allocation of staff and skills were appropriately deployed and shared across all wards. In July 2015 there were still 70 nursing vacancies in medical and acute services across the trust.
  • The trust had a high vacancy rate for nursing staff in medical services trust wide, which was 13% at the time of the inspection. The turnover of nursing staff was 9.7%.
  • The vacancy rate for nurses in surgical services was below 3% for the five month period prior to the inspection. At the time of the inspection the vacancy rate for nurses across surgical services trust-wide was 2.4%.
  • There was no recognised acuity tool in use to determine staffing numbers on paediatric wards. A band 6 nurse devised the staff rota and the skill mix of each shift was based on their knowledge of individual staff competencies.
  • The staffing and skill mix on surgical ward areas and in theatre areas was sufficient, with some periods of reduced staffing in areas because of last minute sickness and unexpected events. However, there was a lack of surgical staff trained in paediatric life support. This training was not mandatory for staff, despite them regularly working with children.

Medical staffing

  • Medical treatment was delivered by skilled and committed medical staff.
  • The information we reviewed showed that medical staffing was generally sufficient at the time of the inspection.
  • The trust had identified areas, such as the emergency department and medical specialties, where medical staff shortages presented a risk to patient care and treatment and were working hard to recruit and retain consultants.
  • The vacancy rate for medical staff was 12.4% and the turnover of medical staff in medical services trust wide was 18% at the time of the inspection.
  • The total number of shifts covered by locum medical staff in medical services trust wide, between April 2015 and September 2015, was 1,428. This was for a number of reasons including vacancies, extra staffing over and above the normal levels and extra ward rounds. Locums were either trust staff working extra shifts or from an agency.
  • The number of palliative care consultants was below the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance.
  • There were 57.4 whole time equivalent (WTE) vacancies across all staffing in the diagnostics and imaging services as of August 2015.

Mortality rates

  • Monthly governance meetings were in place where mortality, incidents and actions were discussed. Information was then cascaded to senior staff via email to enable sharing with other staff. However, in medical services it was unclear if any actions for improvement were agreed at the meeting.
  • The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. Between October 2013 and September 2014 the trust score was 97.

Nutrition and hydration

  • The majority of patients we spoke with said they were happy with the standard and choice of food available.
  • In the CQC accident and emergency patient survey 2014, patients gave the emergency department a score of seven out of ten for being able to access suitable food or drink whilst in the department.
  • Staff in surgical services managed the nutrition and hydration needs of patient’s well, both pre and post operatively. Patients were given information in the form of leaflets about their surgery and told how long they would need to fast pre-operatively.
  • In all the records we reviewed, a nutritional risk assessment had been completed and updated regularly. This helped identify patients at risk of malnutrition and adapt to any ongoing nutritional or hydration needs.
  • A coloured tray system was in place to highlight which patients needed assistance with eating and drinking. The trust had an internal target to ensure that 75% of patients got assistance with eating when they required it. Information provided by the trust showed that they were not meeting this target in medical specialties.
  • Staff consistently completed charts used to record patients’ fluid input and output and where appropriate staff escalated any concerns.
  • The trust was awarded UNICEF baby friendly accreditation in July 2014 for work related to supporting breastfeeding and parent infant relationships.

We saw areas of outstanding practice including:

  • Senior clinicians on the emergency surgical assessment unit had recognised that fluid balance monitoring could be improved and introduced a training programme for health care support workers to achieve this aim. Health care support workers told us they felt empowered by the training and saw fluid balance monitoring as an integral part of their role after it. Audits showed that the completion of fluid balance charts had improved since the training and senior clinicians reported that there had been a significant reduction in the number of patients developing acute kidney injuries (a condition associated with dehydration).
  • The sentinel stroke national audit programme (SSNAP) latest audit results rated the trust overall as a grade ‘A’ which was an improvement from the previous audit results when the trust was rated as a grade ‘B’. Since October 2014 the trust had either been ranked first or second regionally in the SSNAP audit.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the hospital must:

Urgent and emergency care

  • Ensure call bells are available in every bay and placed with patients.
  • Staffing continues to remain a focus and that shifts are adequately staffed to meet the needs of patients.
  • Ensure that risks are always managed and mitigated in a timely way.

Medical care (including older people’s care)

  • The trust must ensure that robust information is collected and analysed to support improvements in clinical and operational practice.
  • The trust must ensure that care and treatment is only provided with the consent of the relevant person and if a patient lacks capacity to consent, the Mental Capacity Act (2005) principles are adhered to. This must be supported by staff receiving training in consent and the principles of the 2005 act.
  • The trust must deploy sufficient staff with the appropriate skills on wards, especially on the medical short stay ward and on ward 16 at night.
  • The trust must ensure that learning is shared across all service areas and the reasons for any changes made clear to all staff.
  • The trust must ensure that records are kept secure at all times so that they are only accessed and amended by authorised people.

Surgery

  • The trust must ensure that there are adequate numbers of suitably qualified staff in theatre recovery areas to ensure safe patient care.
  • The trust must ensure that all staff involved with the care and treatment of children receive adequate life support training.
  • The trust must ensure that all staff receive are appropriately trained and able to use the incident reporting system.

Critical care

  • The trust must address the governance shortfalls in critical care and make sure that the systems and processes in place for assessing, monitoring and mitigating local risk are managed effectively.
  • The trust must ensure that all staff understand the thresholds for reporting incidents and are encouraged to use the electronic reporting system.
  • The trust must make sure that all staff understand and comply with the best practice in infection prevention and control. This includes appropriate use of handwashing and the use of antiseptic hand gels.

Maternity and gynaecology

  • Review the management of the electronic rostering system to ensure it does not allow staff to be rostered on different wards at the same time.
  • The provider must deploy sufficient clinical and midwifery staff with the appropriate skills at all times of the day and night to meet the needs of women following the trust risk assessment and escalation procedures.
  • The provider must ensure that there is a detailed overview of the types and seriousness of incidents and learning is shared across all service areas and the reasons for any changes made clear to all staff.
  • The provider must make sure individual care records are always accurate and completed contemporaneously.
  • The provider must make sure community midwives have easy access to the emergency medication and equipment detailed in best practice guidance. The equipment must be checked and items provided within the use by date.

Children and young people’s services

  • Resuscitation trolleys must be appropriately checked and the log book must be signed to confirm all items are in working order. The trolley must include a defibrillator at all times.
  • Must ensure that there is a robust system to determine staffing numbers which takes into account the acuity of patients and skill mix of staff.

  • Information must be collected and analysed to support developments in clinical and operational practice.

  • Must review the children’s safeguarding training to ensure it meets Royal College of Paediatrics and Child Health (RCPCH) guidelines 2014.

End of life

  • Ensure that any complaint received is investigated and necessary and proportionate action is taken in response to any failures identified by the complaint or investigation.
  • Seek and act on feedback from relevant persons and staff teams, for the purpose of continually evaluating and improving services.
  • Evaluate and improve their practice in respect of the processing of information relating to the quality of people’s experience.
  • Ensure there is a robust vision and strategy for end of life services and all staff are aware of them.
  • Ensure that there is an appropriate replacement care plan in place across the trust following the withdrawal of the Liverpool Care Pathway.
  • Ensure that all risks associated with end of life services are recorded and monitored with appropriate actions taken to mitigate them.

Outpatients and diagnostics

  • The trust must take action to reduce the delay in referral to reporting times of urgent diagnostic investigations.
  • The trust must resume radiation safety committee meetings and hold them at least annually.
  • The trust must take steps to fill vacancies to ensure compliance against their current staffing establishment.

In addition the trust should:

Urgent and emergency care

  • Review and introduce regular audits of patient records to ensure all relevant details are correctly sourced and recorded.
  • Review and evaluate the outcomes from use of the potential sepsis warning tool.
  • Take action to address waiting times and the access and flow through the hospital.

Medical care (including older people’s care)

  • The trust should ensure that hazardous chemicals are stored appropriately in a locked cupboard when not in use.
  • The trust should ensure that the acuity of patients on the coronary care unit is regularly assessed to ensure there is an appropriate skill mix of staff.
  • The trust should ensure that trolleys used to store records and sharp instruments are kept secure when not being used.
  • The trust should ensure those patients are discharged as soon as they are fit to do so.
  • The trust should ensure that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.
  • The trust should ensure that patients’ views are sought to help inform changes to services provided.
  • The trust should ensure that actions to improve standards of medicines management are identified in a timely way.
  • The trust must consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.

Surgery

  • The trust should ensure that the emergency surgical assessment unit is not used for medical outliers.
  • The trust should ensure that patients are not kept in theatre recovery areas for long periods of time or overnight.

Critical care

  • The trust should ensure that all equipment is regularly serviced, maintained and remains fit for purpose.
  • The trust should ensure that all patient records are accurate and fit for purpose.
  • The trust should ensure that any delayed discharges from critical care do not result in a breach of the government’s single sex standard.
  • The trust should consider developing to plans to indicate when facilities will be upgraded to comply with the current HBN 04-02. It is imperative that critical care is delivered in facilities designed for that purpose.
  • The trust should consider how it is going to improve performance in reducing the number of delayed and out of hours discharges of patients from critical care.
  • The trust should consider articulating a vision and strategy for the critical care service and communicating this to its staff.

Maternity and gynaecology

  • The provider should ensure women and babies who are subject to safeguarding or child protection concerns have their needs reviewed before they are discharged from the maternity service.
  • The provider should consider making it possible for all staff to be able to complete incidents directly onto the system
  • The provider should make sure the arrangements for managing medicines and medical gases keep people safe and meet the relevant best practice guidance.
  • The provider should ensure the general public are given opportunities to comment on their strategic plans.
  • The provider should consider providing written information in different languages.
  • The provider should consider maternity and gynaecology working more closely together so that effective systems can be shared.
  • The provider should consider ways of improving staff satisfaction with working for maternity services at Arrowe Park Hospital.

Children and young people’s services

  • The patient electronic system in the emergency department should include a safeguarding identifier to inform staff of known safeguarding concerns.
  • The trust should consider adding a paediatric nurse to the trust wide safeguarding team.
  • A robust development plan should be in place to improve staff skills.
  • The cot space on the neonatal ward should meet British Association of Perinatal Medicine (BAPM) standards.
  • There should be more integrated working between the wards and the children’s assessment unit.
  • All equipment in all areas of the children ward, neonatal unit and the children’s assessment unit should be tested for electrical safety and all plug sockets should have safety plugs.
  • There should be an active board level representative for children and young people’s services.

End of life

  • Ensure policies and protocols are reviewed and monitored regularly to ensure their effectiveness and implementation is consistent across the trust.

Outpatients and diagnostics

  • The trust should take steps to ensure that equipment is available and fit for use with minimal disruption to the service.
  • The trust should ensure that medication is not left unattended when not in use.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 10 March 2016

Effective

Good

Updated 10 March 2016

Caring

Good

Updated 10 March 2016

Responsive

Requires improvement

Updated 10 March 2016

Well-led

Requires improvement

Updated 10 March 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 10 March 2016

Staffing arrangements did not always ensure there were enough skilled and knowledgeable midwives on duty. There was inconsistency in the reporting and review of serious incidents including root cause analysis which lacked robustness in its approach and actions. The record keeping systems did not guarantee that accurate and up-to-date information about patients would be readily available. Patients received consultant and midwifery-led care depending on where they chose to have their babies, and received the support of specialist staff for advice and guidance. Patients were cared for with kindness, compassion and they were positive about the standard of care and treatment. Staff were supported to learn and develop. Only a minority of maternity and gynaecology staff felt there was effective communication between ward staff and senior managers. Best practice guidance in relation to care and treatment was followed and plans were in place to participate in national and local audits. However, many of the audits had been discussed but not commenced. Staff were not supported to be involved in the overall development of the service. There was limited involvement of stakeholders or the general public in the trusts long-term plans for the service. The management structure of the maternity services was relatively new and a system review was being completed. The gynaecology ward and clinics were well run by the gynaecology service and ward managers.

Medical care (including older people’s care)

Requires improvement

Updated 10 March 2016

We previously inspected this hospital in May 2015 and found that there were shortages of nursing staff on some medical wards. Staffing levels had improved since the last inspection but there were concerns in relation to nurse staffing on some of the wards at night and the medical short stay ward. Incidents were reported by staff but the reasons why changes had been made were not always communicated to all staff. Clinical staff had access to information they required, however, when agency staff were used, they were not always able to access the required information. Records trolleys were left unlocked on some of the wards we visited. Best practice guidance in relation to care and treatment was usually followed. Low numbers of staff had received level two and three mental capacity act training which led to some uncertainties about practice amongst staff. A large number of patients were being cared for in non-speciality beds. Some patients had to stay in hospital longer than was needed due to care packages not being in place when they were ready for discharge. Patients received compassionate care and their privacy and dignity was maintained, although there was limited interaction with patients on ward 24. Where possible, patients were involved in their care and treatment and could access emotional support if they needed to. There were governance structures in place. However, some risks were not managed in a timely way. We saw limited evidence that information was collected and analysed to support clinical and operational decisions. The majority of staff said they felt supported and said that morale in medical services had improved over the past six months.

Urgent and emergency services (A&E)

Requires improvement

Updated 10 March 2016

Between December 2014 and April 2015 the emergency department consistently failed to meet the national target to see, treat and discharge 95% of patients within four hours. The number of patients who waited between 4 and 12 hours to be admitted to wards was also consistently higher than the national average. The trust had worked to accurately calculate the right number of staff required to care for patients. However, staff rotas showed that there were often lower than the required levels of nursing and medical staff on duty. Awareness about quality measurement within the department was limited. Actions to manage and mitigate risks were not always undertaken in a timely way. Patients were happy with the care provided and said staff were pleasant. However, call bells were not accessible to patients across the department. Staff were below the trust target of 95% for mandatory training and only 50% of medical and nursing staff had completed safeguarding training to the required standard. The trust had responded positively to concerns in relation to the identification and management of sepsis by implementing a sepsis pathway and an electronic tool to support the recognition of potential sepsis and prompt early intervention. Policies and procedures were evidence based and developed in line with national guidance from professional bodies such as the Royal College of Emergency Medicine. Multi-disciplinary working was evident within the department, trust and wider community. Staff told us that the emergency department (ED) had developed an open and honest culture and excellent teamwork. There was a shared vision for the future of patient care.

Surgery

Good

Updated 10 March 2016

Care and treatment was provided in line with national and best practice guidance. The auditing of care and treatment was undertaken on regular basis. Patients received care and treatment from competent staff who worked well as part of a multidisciplinary team. Most patients had a positive outcome as a result of being treated within the service. Patients were treated with kindness, dignity, compassion and their relatives were involved in their care and treatment. There were low rates of avoidable harm including infections and pressure ulcers. Records were completed correctly and legibly and the majority of staff were up to date with their mandatory training. Medicines were well managed and appropriately stored. Patient records were clear, legible and up to date. The environment and equipment were generally visibly clean and well maintained. The service managed complaints well and we saw evidence that learning from complaints took place. Staff were aware of the trust’s vision. Managers and leaders were visible and known to staff. There was evidence that the service strived to continually improve through public and staff engagement. Staff did not always report incidents because of a lack of training on how to use the system. When incidents were reported, feedback was not consistently given. Nurse staffing levels were sufficient on the surgical wards and in theatre areas. However, nurse staffing levels within theatre recovery were insufficient at times. This impacted on anaesthetic staff who stayed to observe patients. In addition, we found that most staff had not undertaken paediatric life support training despite regularly caring for children. There were a number of shifts identified where there were no paediatric life support trained nurses on duty.

Intensive/critical care

Requires improvement

Updated 10 March 2016

There were sufficient numbers of suitably skilled nursing and medical staff to care for the patients. However, we found examples of incidents that were not reported. The clinical areas did not meet national guidance. Monitoring equipment and ventilators needed to be replaced but there was no clear plan in place to ensure capital funding was available to facilitate this. Transfer equipment for critically ill adults did not meet the current Intensive Care Society standard. Hand hygiene best practice was not being followed by all staff. There was no clear, shared vision or strategy for the unit. There was a governance structure in place though at times it was unclear how risks were being, monitored, managed and reviewed. Patient outcomes were within the expected ranges when compared with similar critical care units nationally. We saw patients, their relatives and friends being treated with care, compassion, dignity and respect.

Services for children & young people

Requires improvement

Updated 10 March 2016

The systems to devise staffing numbers on the paediatric ward were not robust. Staff knew how to report incidents but did not always know what constituted an incident. There were concerns about equipment on the paediatric ward as the resuscitation trolley was not locked and did not have a defibrillator on it. We found some controlled drugs which had expired. The safeguarding policy did not refer to current guidance. We identified gaps in safeguarding case notes such as incomplete MARS (Multi Agency Referral Service) forms. Hand hygiene was good, staff washed their hands between patients and used aprons to reduce the risk of infection spreading. The neonatal unit did not meet the British Association of Perinatal Medicine (BAPM) standards for cot space which sometimes impacted on the number of babies that could be admitted. The service participated in national and local audits and the results were within national averages. A transition policy wasn’t in place for children with long term health needs and nursing staff were unclear how to initiate a child’s transfer to adult services in line with guidance. The community paediatric service consistently failed to meet national referral to treatment targets and the waiting list was lengthy with some children waiting up to 47 weeks. However, services for children at Arrowe Park Hospital consistently met the national referral to treatment targets. Parents and young people felt safe and informed about their treatment. We observed patients been looked after with respect and dignity. Training and development of staff on the paediatric ward was not a priority and staff told us they were not supported to develop themselves. Care on the neonatal unit was well managed and local leadership on the unit was clear and directive. The unit constantly looked at ways to improve care. There were governance structures in place. However, some risks on the register had been there since 2012 with actions still being completed.

End of life care

Requires improvement

Updated 10 March 2016

There was an insufficient number of general nursing staff who had received appropriate training in end of life care. The palliative care consultant staffing levels across the trust were below the recommended guidelines. The trust performed worse than the England average in the National Care of the Dying Audit, published in May 2014. The trust’s policy did not clearly specify in which cases staff were required to complete do not attempt cardio-pulmonary resuscitation (DNA CPR) forms or how long after a patients admission they had to complete them. When DNA CPR decisions were recorded, this information was not always readily available to staff if a patient re-presented at the hospital following their discharge. There was a draft three-year vision developed by the trust’s end of life care committee. However, we found no evidence that this had been communicated to staff. There was no overarching monitoring of the quality of the service across the trust. Complaints were not always responded to appropriately. Interim guidance and a toolkit had been put in place following the removal of the Liverpool Care Pathway nationally in 2013. Whilst a replacement care plan had recently been agreed not all staff were aware of it and we did not see it being used. Specialist palliative care (SPC) nurses were able to describe safeguarding procedures and provided us with examples of how these would be used. Staff were aware of how to report an incident or raise a concern. Appropriate equipment was available to patients at the end of their life and it was adequately maintained. Medicines were managed appropriately. Patients were involved in care planning and decision making. Staff were respectful and treated patients with compassion. Specialist palliative care team members were visible, competent, and knowledgeable. Staff within the SPC team were very motivated and committed to meeting patients’ individual needs at the end of life and were actively developing their own systems and projects to help achieve this.

Outpatients

Requires improvement

Updated 10 March 2016

There were significant staff vacancies across the whole trust in diagnostic and imaging services. The service failed to meet the national target in July and August 2015 for referral to treatment times. In addition, the trust failed to meet their internal target for urgent reporting of plain x-rays between April 2015 and August 2015. The radiology department had equipment that exceeded the recommended ten year life span and regular equipment failures caused delays for patients. There were a large number of clinic appointments cancelled due to the process in place for rebooking appointments. Managers had plans to implement a partial booking system to reduce cancellation of appointments and to offer patients more choice. Some clinical governance measures were in place for radiology however, there had been no radiation safety committee meetings since September 2012. We saw that teams worked well locally but some staff were not formally made aware of key issues following complaints, incidents and audits. Staff felt supported by their local managers however Patients were treated in a dignified and respectful way by caring and committed staff. There was a clear process for reporting and investigating incidents and staff received feedback. Records were available for 99% of outpatient appointments. Mandatory Training was well attended and staff were aware of their role and responsibilities in relation to safeguarding. The leadership and governance arrangements did not always support the delivery of high quality care. Staff shortages had been identified and placed on the risk register. However, progress was slow to resolve the issue. Cleanliness and hygiene was of a good standard throughout areas we visited and staff followed good practice guidance in relation to the control and prevention of infection.