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Inspection Summary


Overall summary & rating

Good

Updated 15 January 2015

Leighton Hospital is one of three locations providing care as part of Mid Cheshire Hospitals NHS Foundation Trust. It provides a full range of hospital services including emergency care critical care, coronary care, general medicine including elderly care, general surgery, orthopaedics, anaesthetics, stroke rehabilitation, paediatrics and midwifery-led maternity care. The trust also provides outpatient services and a minor injuries unit at Victoria Infirmary and intermediate care services at Elmhurst Intermediate Care Centre.

Mid Cheshire Hospitals NHS Foundation Trust provides services to a population of approximately 300,000 living in and around Alsager, Crewe, Congleton, Knutsford, Middlewich, Nantwich, Northwich, Sandbach and Winsford.

We carried out this inspection as part of our comprehensive inspection programme.

We carried out an announced inspection of Leighton Hospital between 8 and 10 October 2014. We also carried out an announced inspection of the Victoria Infirmary. In addition an unannounced inspection was carried out between 5pm and 8.30pm on 24 October 2014 at Leighton Hospital only. As part of the unannounced visit we looked at the management of medical admissions out of hours.

Due to the size and nature of services provided at the Victoria Infirmary we have included our findings for this service within the core service reports for outpatients and emergency & urgent care services.

Overall we rated Leighton Hospital as ‘good’. We have judged the service as ‘good’ for safe, caring, effective and well-led care and noted some outstanding practice and innovation. However improvements were needed to ensure that services were responsive to people’s needs.

Our key findings were as follows:

Access and patient flow

  • Due to the numbers of emergency admissions there was continual pressure on the availability of beds at the hospital. This meant that some patients were not placed in the area best suited to their needs. As a result the management of patient access and flow across the hospital was of concern and remained a significant challenge for managers. The hospital had made sound arrangements to ensure the timely medical review of patients. However, some of the areas used for escalation beds, especially the primary assessment area, did not provide an appropriate environment for the care of patients overnight. The trust had implemented the Golden Patient initiative to ensure that patients did not spend more than 23 hours in this area and were moved to a setting more suited to their needs at the earliest opportunity.
  • There were occasions when patients were moved from ward to ward, sometimes at night due to pressures on bed availability.
  • There were also pressures placed on bed capacity by the number of delayed discharges.
  • Patient discharge letters were not always issued to GPs in a timely way. In addition the quality of information included in the letters varied considerably. This was of concern as poor communication with GPs and others can lead to delays and confusion in managing patients’ care going forward.

Cleanliness and infection prevention and control

  • Patients received care in a clean, hygienic and suitably maintained environment.
  • Appropriate equipment was in good supply and was clean and well maintained.
  • Staff were aware of and applied infection prevention and control guidelines.
  • We observed good practices in relation to hand hygiene, ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.

Medical staffing

  • Medical treatment was delivered by skilled and committed medical staff.
  • However, there were not always enough medical staff to provide timely treatment and review of patients, particularly during out of hours.
  • Shortages of medical staff also meant that some patients waited for long periods in outpatients as medical staff were sometimes called to the wards or emergency department to see patients whose condition had deteriorated.
  • The trust was working hard to recruit and retain consultants. It had a number of initiatives in place including cross working with neighbouring trusts and recruiting medical staff from overseas. These initiatives were helping to address medical shortfalls. Nevertheless, the shortage of medical staff meant that patients sometimes waited for extended periods of time to be seen by a consultant.
  • There was also a shortage of trainee doctors. This was being taken forward by the Medical Director with the regional training schools, with a view to the trust being allocated a full complement of trainee doctors. This would alleviate pressures on the existing team and free up more senior colleagues so they could see patients quickly.
  • The pressures on the medical workforce had also led to delays in discharge letters to GPs. There were also concerns about the quality and content of the discharge letters as they were of variable quality and clarity. The lack of clarity had the potential to lead to confusion about who was responsible for the ongoing care of patients. The trust had recognised this as an issue and had begun to pay medical staff overtime to reduce the backlog. However, there were a number of wards and departments that were still struggling to send out this important information in a timely way.

Nursing staff

  • Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services. However nurse staffing levels, although improved, remained a challenge. The trust was actively recruiting nursing staff from overseas to try and improve staffing levels.
  • Although we found staffing levels were adequate at the time of our inspection, there was no flexibility in numbers to cope with increased capacity and demand, or short notice sickness and absence.
  • Nurse staffing on the critical care unit did not always meet best practice requirements.

Mortality rates

  • Our intelligent monitoring report highlighted the trust as being an elevated risk for mortality rates. The medical director took the lead for addressing this and implemented an action plan that appears to be effective. The plan included partnership working with community providers and commissioners and is reducing HSMR and SHMI rates.
  • The trust showed insight in understanding the mortality data and identifying any potential improvement areas for patient safety or the patient pathway. In addition, work had been undertaken with the coding team and the medical staff to improve the coding information. Changes in coding practice had been made and the trust was confident that its mortality data quality had improved and would continue to do so.
  • Mortality and morbidity meetings were held weekly and were attended by representatives from all teams within the relevant divisions. As part of these meetings, attendees reviewed the notes for every patient who had died in the hospital within the previous week. Any learning identified was shared and applied.
  • While we were carrying out our inspection the latest SHMI data became available. This indicated that the trust was moving nearer to expected levels at 104, continuing the positive downward trend. The trust stated its intention to remain proactive and vigilant in understanding and improving its mortality rates.

Nutrition and hydration

  • Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team.
  • There was a period over mealtimes when all activities on the wards stopped, if it was safe for them to do so. This meant that staff were available to help serve food and assist those patients who needed help. There was a coloured tray system in place so that patients who needed assistance with eating and drinking could be easily identified and offered appropriate and discreet support.

Medicines management

  • Medicines were provided, stored and administered in a safe and timely way.
  • Anticipatory end of life care medication was appropriately prescribed. Patients who had moved into the community on an end of life pathway were sent home with prescriptions including a signed prescription chart. This was good practice as it enabled community nurses to give symptomatic relief without delay from the time the patient arrived home.

We saw several areas of outstanding practice including:

  • In medical care, the trust had introduced an electronic handover tool (e-handover) for which they had received a Health Service Journal Award. Medical staff at the trust had developed documentation for the care of patients on an alcohol detox pathway.
  • The new critical care unit had been designed in accordance with the latest best practice guidance with the aim of reducing delirium and the problems associated with sensory deprivation. For example the rooms on one side of the unit benefitted from full length windows incorporating an electronic blind so that natural light was visible. In addition the unit made use of sky ceiling photo panels above patient beds, which displayed realistic images of blue skies, white clouds and blossom trees.
  • The end of life care service had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medication.
  • The hospital had a rapid discharge pathway to enable patients to be discharged from the acute hospital to home in the last hours /days of their lives. An audit in March 2014 showed that the preferred place of care (PPC) was achieved for 84% of patients seen by the specialist palliative care team (SPCT) and PPC wishes were met for 96% of the patients seen by the team.

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

Importantly, the trust must:

  • Ensure that medical staffing is sufficient to provide appropriate and timely treatment and review of patients at all times including out of hours.
  • Ensure that medical staffing is appropriate at all times including medical trainees, long-term locums, middle-grade doctors and consultants.

  • Improve patient flow throughout the hospital to reduce the number of patient bed moves and patients’ length of stay – particularly in the medical division.

  • Take action to clear the backlog of discharge letters, and implement an effective system for managing discharge letters so that GPs receive accurate and robust information about their patients in a timely way

  • Ensure that escalation areas are appropriate environments for the care of patients and provide them with ready access to bathing and toilet facilities.

In addition the trust should:

  • Consider improving arrangements for clinical supervision to ensure they are appropriate and support staff to effectively carry out their responsibilities, offer relevant development opportunities and enable staff to deliver care safely and to an appropriate standard.
  • Ensure that, where patients are deemed not to have capacity to consent, staff are establishing and acting in accordance with the best interests of the patient and that this is appropriately documented.

In emergency & urgent care services:

  • Ensure that all staff complete their mandatory training in a timely manner.
  • Consider updating the sudden death checklist for paediatrics to include a “do not leave child alone with parents” step.
  • Ensure they have a list of appropriate staff that have been trained with the required scene safety and awareness training.

In medical care services:

  • Ensure timely access to treatment for upper gastrointestinal bleeds and stroke thrombolysis, including out of hours.
  • Ensure action is taken to improve outcomes for patients with diabetes or who have had a stroke.

In surgery services:

  • Ensure that appropriate action is taken to reduce the number of elective surgical patients that are readmitted to hospital following discharge.
  • Continue to monitor and fully implement the proposed actions in order to reduce the number of cancelled operations and improve theatre utilisation.

In maternity & gynaecology services:

  • Review and improve the provision of consultant anaesthetic sessions for elective caesarean sections to provide a more responsive service for women.

In services for children & young people:

  • Consider reviewing safeguarding children training to ensure that the format, content and duration is in line with best practice guidance, in particular the provision of inter-agency training, and that the time allowed for level 3 training is appropriate to support the learning needs of staff
  • Ensure that safeguarding concerns are reported via the incident reporting systems to make sure that incidents are fully investigated, and provide assurance that all relevant staff are aware of lessons learned.

In outpatients and diagnostic imaging services:

  • The trust should take action to ensure that waiting times for outpatient clinics are improved and that clinics do not over run leading to cancellation of appointments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 15 January 2015

Effective

Good

Updated 15 January 2015

Caring

Good

Updated 15 January 2015

Responsive

Requires improvement

Updated 15 January 2015

Well-led

Good

Updated 15 January 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 15 January 2015

Maternity and gynaecology services provided good and effective care in accordance with both local and national guidance. We found midwifery staffing levels were calculated using a recognised dependency tool.

A triage service introduced by the service enabled women to be directed to the most appropriate support in a timely manner. However there was no dedicated list for elective caesarean sections. As a result we found that patients may have their surgery delayed if an emergency arose. In addition, anaesthetic support was provided on a second on call basis from the main critical care service. This could also lead to delays for women.

There were systems in place for reporting actual and near miss incidents across the maternity and gynaecology services. The service monitored all its risks and had local risk registers. Action plans were in place and regularly monitored to ensure that risks had been addressed. Staff had a good knowledge and understanding of the need to ensure that vulnerable people were safeguarded.

Staff understood and followed best practice infection control guidance. Services were delivered by committed, caring and compassionate staff. We observed that staff treated mothers and their partners with dignity and respect and planned and delivered care in a way that took their wishes into account. Emotional support was available for both mothers and their partners.

Medical care (including older people’s care)

Requires improvement

Updated 15 January 2015

Medical services at Leighton Hospital were well-led, and delivered by caring and compassionate staff. We observed staff treating patients with dignity and respect and patients we spoke with were positive about their interactions with staff.

However, clinical outcomes for patients in some areas required improvement. Our analysis of data showed that particular improvements were needed in the management of patients with diabetes and those who had had a stroke. There also gaps in the provision of some out-of-hours services for patients with upper Gastrointestinal (GI) bleeds and in providing thrombolysis for patients that had suffered a stroke. In addition, some specialist nursing posts had not been filled at the time of our inspection.

Patients were regularly at Leighton Hospital longer than they needed to be, usually as a result of delays in providing, or the availability of, care home placements or care at home packages.

Discharge letters were not prepared and issued promptly, leading to possible delays in follow-up care and treatment for patients. There was continual pressure on the availability of beds which meant that some patients could not be placed in an area best suited to their needs. Some of the areas used for escalation beds, especially the primary assessment area, did not provide an appropriate environment for the care of patients overnight.

Urgent and emergency services (A&E)

Good

Updated 15 January 2015

There were good systems in place for reporting and managing incidents. There was a risk-aware culture in the department and a willingness to learn from incidents. Patients received care in a clean, hygienic and suitably maintained environment. Appropriate equipment was in good supply and was clean and well maintained. Medicines and records were managed effectively and safely within the department. The staffing levels were sufficient to meet patients’ needs and processes were in place to ensure resource and capacity risks were managed and mitigated. There were efficient and well managed processes in place for the handover of patient information to ensure continuity of appropriate care and treatment. The trust had an up-to-date major incident plan that listed key risks and actions to maintain the provision of care during a major emergency.

Patients received care and treatment that was based on evidence-based practice and a national guidance. Multi-disciplinary team working was well established and used effectively to manage patients’ individual care and treatment needs. Staff treated patients with dignity, compassion and respect. Staff provided patients and their families with emotional support and comforted patients who were anxious or concerned about their condition and treatment options.

The emergency department faced a number of challenges, including the management of increasing emergency admissions and changes in the needs of the local population. The trust had carried out a significant amount of work to tackle the capacity and patient flow challenges that had affected their A&E performance. Performance was improving and staff were engaged, enthusiastic and proud of the improvements achieved. The organisation’s vision and strategy had been cascaded to all staff. There was clearly defined and visible leadership within the department and staff felt there was an open and supportive culture.

Surgery

Good

Updated 15 January 2015

Surgical services provided good care and treatment for patients. Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in clean, hygienic and suitably maintained premises. The staffing levels and skills mix was sufficient to meet patients’ needs and staff assessed and responded to patient risks appropriately

Surgical services provided effective care and treatment based on evidence-based national clinical guidelines and staff used care pathways appropriately. The services participated in national and local clinical audits to benchmark and improve care and treatment for patients. Surgical outcomes were, in the main, positive. However, the number of patients that had elective surgery and were readmitted to hospital following discharge was worse than the England average. There were plans in place to improve areas where national clinical and performance standards had not been achieved, such as compliance with the national hip fracture audit.

Patients received care and treatment by trained, competent staff that worked well as part of a multidisciplinary team. Patients spoke positively about their care and treatment. Patients were treated with dignity and received their care in a compassionate way. Surgical services were planned and delivered to meet the needs of local people. There was sufficient capacity to ensure patients admitted to the surgical services could be seen promptly and receive the right level of care. There was effective teamwork and clearly visible leadership within the surgical services. There was a positive culture within the service that was focused on patient safety and learning. There was routine public and staff engagement and actions were taken to improve the services in response to patient feedback. The management team understood the key risks and challenges to the service and how to resolve them.

Intensive/critical care

Good

Updated 15 January 2015

The trust was providing a good critical care service overall. However, to maintain safe care, some improvements were required relating to medical and nursing staff numbers.

There was evidence of strong medical and nursing leadership in the critical care unit that led to positive outcomes for patients. The service submitted regular Intensive Care National Audit and Research (ICNARC) data so was able to benchmark its performance and effectiveness alongside other units nationally.

There was a clear understanding of incident reporting and an embedded culture of audit, learning and development. However, the unit’s risk register contained risks had been there for a number of years and it was not clear whether these had been reviewed as planned or what the actions were.

The unit employed two nurses specifically in practice educator roles, which enabled them to support both new staff and those requiring additional support or performance management. Based in critical care, there was also a well-developed outreach service staffed on a daily basis by experienced band 7 nurses from the critical care unit. On the days of our inspection the unit had five to six empty beds at the start of the morning shift. It was safely staffed with the appropriate number of trained nurses per patient plus a senior co-ordinating nurse, clinical services manager and both junior and consultant medical staff.

Services for children & young people

Good

Updated 15 January 2015

Care provided by services for children and young people was supportive to children, young people and their families. People told us that the staff were “lovely” and “very kind”. There were processes in place for safeguarding and such concerns were identified and referred to the relevant authorities. There were robust arrangements in place to report and monitor incidents and near misses. Staff were clear about their responsibilities in this regard. However the process for reporting safeguarding concerns via the incident reporting system was not as robust. This meant that incident reporting systems may not accurately reflect the safeguarding concerns identified.

There were clear governance arrangements in place that monitored the outcome of audits, complaints, incidents and lessons learned throughout the service. Staff were positive about the culture in children’s and young people’s services and felt supported by their senior managers. Staff were able to be innovative and introduce new practices to improve the quality of the service provided.

Children’s and young people’s services were forward thinking in how services could to be adapted to provide flexibility and sustainability in the future. There was a strong commitment to developing relationships across health networks.

End of life care

Good

Updated 15 January 2015

Patients received a good standard of end of life care that involved relatives and carers. Care was provided by supportive and compassionate staff who respected patients’ need for privacy and dignity. Nursing and care staff were appropriately trained and they were encouraged to learn from incidents. Relatives of patients, nurses and doctors spoke positively about the service provided from the Specialist Palliative Care Team (SPCT). End of life care services worked collaboratively with both primary and tertiary care services to best meet patients’ individual needs.

Patients and those close to them spoke positively about the rapid discharge pathway that enabled patients to be discharged from hospital to home in the last hours/days of their lives. Staff gave examples of how this policy worked in practice and where this had happened for patients. There were also several examples of how the service met the spiritual, religious, psychological and social needs of patients. Future plans for the service included the introduction of the AMBER care bundle, a system that would provide a systematic approach to manage the care of hospital patients facing an uncertain recovery and who are were at risk of dying in the next one to two months.

The trust had policies and a number of monitoring systems in place to ensure that it delivered good end of life care. However there was limited medical input to the SPCT. General medical cover was provided on the wards for patients with end of life care needs. There was only one part-time consultant (two sessions per week) in palliative medicine.

Outpatients

Good

Updated 15 January 2015

Patients attending the outpatient and diagnostic imaging departments were treated in a dignified and respectful way by caring and committed staff. Staffing numbers and skills mix met the needs of the patients in the department. However, consultants were sometimes called away to deal with emergency situations in other parts of the hospital or clinic’s over ran the times allocated. This meant that, at times, patients waited a long time to see their doctor.

There was a clear process for reporting and investigating incidents. Learning from incidents was shared and there were examples of changes in practice in response to incidents. Staff received training in safeguarding adults and children, the mental capacity act, health and safety, patient confidentiality and infection control.

The outpatient and diagnostic imaging departments were clean and well-maintained although the outpatient departments were sometimes quite cramped in terms of space and seating arrangements. Patient records generally were available for clinics and were secured and stored securely. There were occasions in the dermatology clinics at Leighton Hospital when patient records were not available for an appointment. In such cases staff prepared a temporary file for patients that included the most recent diagnostic and test results coupled with essential patient information so that the patient’s appointment could go ahead. Staff acknowledged that this was not ideal; however it meant the patient did not have to reschedule their appointment.

There was good local leadership and a positive culture within the service. Staff worked well as a team and supported each other.