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Inspection Summary


Overall summary & rating

Good

Updated 22 May 2015

Liverpool Women’s Hospital is one of two locations providing care as part of Liverpool Women’s NHS Foundation Trust. This hospital provides a range of specialist services for women including inpatient and community maternity services, which deliver approximately 8,000 babies a year, a neonatal service to support newborn babies needing specialist care, obstetrics, gynaecology, gynaecology oncology, termination of pregnancy and a unique emergency room for patients who have urgent gynaecological problems or women with problems in early pregnancy (at fewer than 16 weeks). The trust is also a major obstetrics, gynaecology and neonatology research hospital, one of only two specialist trusts in the UK, and the largest women’s hospital of its kind in Europe.

Liverpool Women’s NHS Foundation Trust serves more than 30,000 patients from Liverpool, the surrounding areas and across the UK.

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

We carried out an announced inspection of Liverpool Women’s Hospital on 18 and 19 February 2015. In addition, we undertook an unannounced inspection between 4pm and 7pm on 4 March 2015. As part of the unannounced visit, we looked at maternity and surgical services.

Overall we rated Liverpool Women’s Hospital as good although we found that the Community Maternity Service required improvement. There were plans in place to reconfigure and integrate the community service. The plans had not yet been implemented at the time of our inspection.

Our key findings were as follows:

Overall we found that the hospital provided effective care with outcomes comparable with or above expected standards. Patients were very positive about the care and treatment they received at the hospital.

Staff were positive about the additional investment in midwifery and nursing staff and morale within the hospital had improved as a result.

The senior team was visible and accessible to staff and managers were seen as supportive and approachable. Managers were keen to engage and include staff in service development. There were some concerns raised in relation to the leadership style in the Labour Ward that managers have committed to exploring and addressing.

There was a positive and enthusiastic culture throughout the hospital. Staff were committed and passionate about their work and proud of the services they offered to patients. Staff were keen to learn and continuously improve the services they offered to patients.

Nurse and Midwifery staffing

Nurses and Midwives were caring and compassionate and treated patients and those close to them with dignity and respect. They were committed to giving patients a high standard of care and treatment. Staffing levels were calculated using a recognised tool and regularly reviewed.

Since our last inspection there had been a significant increase in the numbers of nurses and midwives employed and there were sufficient numbers to meet the needs of patients. There were plans in place to increase the number of neonatal nurses to meet the British Association of Perinatal Medicine (BAPM) standards. At the time of the inspection, staffing was sufficient to meet the needs of babies being cared for as current neonatal staff were working extra hours to fill in gaps on the staffing rota.

The neonatal service had introduced the Advanced Neonatal Nurse Practitioner (ANNP) role. The ANNPs were having a positive effect in supporting high quality care for babies requiring specialist neonatal support, however, it was acknowledged that more work was required to fully embed and integrate this key role within the service.

Medical staffing

Medical treatment was delivered by skilled and committed medical staff. There were excellent examples of medical staff providing strong leadership and active engagement in the design and development of services.

There were sufficient numbers of consultants and middle grade doctors to provide good quality care and treatment for patients; however, in maternity – inpatient services, the consultant cover was only 77 hours, which was lower than the 98 hours minimum recommended by the Royal College of Obstetrics and Gynaecology for a unit this size. Junior medical staff were well supported and provided with excellent teaching and learning opportunities.

The tier 1/middle-grade staffing levels were acceptable in terms of establishment but frequently the neonatal unit operated below the establishment. In response to this, the service had introduced an Advanced Neonatal Nurse Practitioner role to help and support junior doctors working in the unit.

Safeguarding

There were robust policies and procedures in place for raising child safeguarding concerns. These processes were supported by staff training. All relevant staff had received appropriate levels of training for safeguarding children.

Staff were aware of the process and demonstrated a good understanding of their role in safeguarding vulnerable children. Interagency working was well developed and there was good communication with relevant professionals in this regard.

Staff training for the safeguarding of vulnerable adults had recently been introduced. Staff were developing their understanding, competency and knowledge in this area at the time of our inspection. Staff training figures indicated that by March 2015 95% of relevant staff would have received Adult safeguarding training.

Safeguarding practice was supported by a trust wide safeguarding team that staff could access for advice and support. However, we did find some examples in the surgical service where the approach to the safeguarding of adults required further development.

There were specialist clinics in place, supported by a Somali health link worker, to identify and address the needs of women who had experienced female genital mutilation (FGM) and designated midwives within the community service to support women whose circumstances had been identified as making them vulnerable.

Incident reporting

There were established systems for reporting incidents and ‘near misses’. Staff had received training and were confident in the use of the incident reporting system. The latest national reporting and learning system (NRLS) data (September 2014) stated that the organisation had a reporting rate of 68.48 per 1000 bed days, which was higher than the median of 35.92 for the cluster of acute specialist trusts. The trust were in the highest 25% of reporters. The trust was however slow to upload incidents to the NRLS system with 50% of incidents submitted more than 41 days after the incident had occurred.

The reporting rates had improved significantly from the previous reporting period. Managers had identified that it was ‘no harm’ and ‘near miss’ incidents that were not being reported appropriately. This was supported by the NRLS report, which highlighted that the percentage of incidents reported by the trust in which no harm had been caused was 51%, compared with 76% across all acute specialist organisations.

There was low incident reporting for all types of incidents in the community maternity service. The trust was working with its staff teams to address this issue and to encourage and support staff to report all incidents appropriately. Managers realised that the poor patient safety incident reporting culture could hinder staff in identifying risks and the trust in taking action to prevent avoidable harm to patients.

There were good examples of learning from incidents. Staff in all clinical areas were able to describe changes in practice following incident investigations. To support learning from Serious Incidents, staff were provided with a one-page summary of the key findings and recommendations to disseminate the learning across their service.

Cleanliness and infection control

There was a visibly high standard of cleanliness throughout the hospital. Staff were aware of current infection prevention and control guidelines and observed good practice. Hygiene audits demonstrated a high level of compliance. There were suitable arrangements for the handling, storage and disposal of clinical waste, including sharps.

Cleaning schedules were in place and displayed throughout the ward areas and departments. There were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.

Staff were vigilant in managing and preventing infection risks. There were services in the hospital whose practice in infection control was exemplary.

Nutrition and hydration

People were given a choice of suitable and nutritious food and drink, and we observed hot and cold drinks available throughout the day.

Patient’s religious and cultural needs were considered and food was provided in accordance with their requirements. Staff provided appropriate and discreet support for those patients who needed help with eating and drinking.

Specialist dietary support was available to patients whose condition indicated or required a specialist diet.

The hospital had a team of midwives, support workers and infant feeding advisers who helped support women to feed their babies. The hospital team was supported by Liverpool BAMBIS (Babies & Mums Breastfeeding Information and Support), a team of peer supporters who offer breastfeeding support and information to pregnant women, breastfeeding mothers and their families.

Access to services

Services were planned to meet the diverse needs of patients using the hospital and community based service. There were access points designed so that pregnant women without a GP could self-refer. There was a unique gynaecological emergency service that provided immediate support to women who again could self-refer.

A link booking clinic was held at Liverpool Women’s Hospital for women whose first language was not English. The Birth Choices Clinic provided support throughout pregnancy to women with tokophobia (fear of childbirth) and a vaginal birth after caesarean section (VBAC) clinic was also available.

There was a specialist clinic, supported by a Somali health link worker, to identify and address the needs of women who had experienced female genital mutilation (FGM) and designated midwives within the community service to support women whose circumstances had been identified as making them vulnerable.

We saw several areas of outstanding practice including:

  • The implementation of the HeRo system. The neonatal unit was the first in the country to put this system into practice.
  • The neonatal unit’s benchmarking of its practice and outcomes against other units in the UK and the USA.

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

Importantly, the hospital must:

  • Improve the way in which medicines are managed and stored.
  • Check the folder of medication data sheets in each room within the neonatal unit at more regular intervals; and confirm with a signature that they have been checked and are valid.
  • Store the portable box containing emergency medicines in the high dependency unit securely.
  • Provide appropriate neonatal resuscitation equipment in the maternity assessment unit.
  • Provide effective controls to prevent the abduction of infants from the labour ward and the Catharine Medical Centre.
  • Ensure that risks regarding the storage of formula milk are appropriately assessed, and effective controls implemented to manage those risks.
  • Provide operating department practitioners or suitably qualified midwives in theatre recovery outside of normal working hours.
  • Ensure that the telephone triage line is staffed at all times.
  • Ensure that, when restraint is necessary, it is undertaken in accordance with the relevant regulations and legislation.
  • Ensure that paper medical records are of an adequate standard and provide an accurate, up-to-date record of the consent, care and treatment provided.
  • Ensure that all staff are able to safeguard adults appropriately.

In addition the hospital should:

  • Review the number of hours of consultant cover in maternity, which were lower than the recommended minimum from the Royal College of Obstetrics and Gynaecology for a unit this size.
  • Ensure that issues identified during audits are addressed.
  • Review the numbers of incidents reported in all services.
  • Ensure that domestic violence referrals from the police are reviewed within agreed timescales.
  • Review practice with regard to the artificial rupture of membranes during induction of labour.
  • Improve the response rates for the NHS Friends and Family Test.
  • Consider including emergency appointments in the induction suite diary.
  • Ensure that there is an effective system in place for testing portable electrical appliances.
  • Allocate a non-executive director with responsibility for termination of pregnancy services.
  • Review the timing of resuscitation decisions so that discussions are initiated with patients at a time when they are well enough to fully consider their wishes.
  • Initiate work on advanced care planning with patients at a time when they are well enough to fully consider their wishes.
  • Monitor the quality of care planning on the wards against patients’ assessed needs.
  • Provide dementia training for ward staff.
  • Address the leadership issues and staff morale within the intrapartum areas.
  • Address the role of the advanced neo-natal practitioners (ANNPs) so they are clear where their role sits and take steps to involve them in developments in the neonatal service.
  • Consider the provision of newborn life support training for community Midwives.

  • Consider auditing the availability of patient records.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Updated 22 May 2015

Effective

Updated 22 May 2015

Caring

Updated 22 May 2015

Responsive

Updated 22 May 2015

Well-led

Updated 22 May 2015

Checks on specific services

Maternity (community services)

Requires improvement

Updated 22 May 2015

There were systems in place for reporting actual and ‘near miss’ incidents in the community maternity service. The service monitored all its risks and had local risk registers. However, we did not see evidence that identified risks had been addressed and mitigated. Additional areas of concern included equipment that was not regularly maintained and medicine stocks, carried by community midwives, that were out of date. Midwifery staffing levels were calculated using a recognised dependency tool and were sufficient to meet the needs of patients. Staff had a good knowledge and understanding of the policies and procedures to promote the safeguarding of women and babies at risk of abuse and neglect. Staff observed, understood and followed best practice infection control guidance. Services were delivered by caring and compassionate staff. We observed that staff treated women with dignity and respect, and planned and delivered care in a way that took women’s wishes into account. Emotional support was available for both mothers and those close to them. Most women were offered a choice with regard to their preferred place of birth and the service ran an on-call system for women choosing home birth. The caseload ratio (midwife to woman) was 1:92, which was similar to the national average of 1:96. Integration between the hospital and community teams could be further developed.

Maternity (inpatient services)

Good

Updated 22 May 2015

Overall we found that the inpatient maternity service was providing a good service to women and their babies.There had been a significant improvement in the numbers of midwifery staff across the service, and this was having a positive impact on patient safety as there were more midwives to deliver care to women and their babies. However, there were areas relating to safety that required improvement. The maternity assessment unit did not have any equipment with which to resuscitate a newborn baby. Medicines were not always stored at the correct temperatures and an appropriate tracking system for keys to patient medication lockers was not in place.The storage of formula milk was not well managed. Effective controls were not in place to prevent the abduction of infants from the labour ward and the Catharine Medical Centre. Midwifery staffing levels were satisfactory across the service; however the number of hours of consultant cover (77 hours) were lower than the recommended minimum (98 hours) from the Royal College of Obstetrics and Gynaecology for a unit this size. The ward and clinical areas were visibly clean and well maintained. National guidelines were followed in treating patients and the outcomes for patients were comparable with other trusts nationally, although a small number of women were unable to access their chosen method of pain relief during labour. Patient care and treatment were delivered effectively by a multidisciplinary team 7 days a week both within and outside normal working hours. Midwives required to work in theatre recovery needed additional training. Integration between the hospital and community teams could be further developed. Maternity services were delivered by caring and compassionate staff. Staff treated patients with dignity and respect. Care was planned and delivered in a way that took into account the wishes of the patients. The services were, in the main, responsive to patients’ needs. They were planned and delivered to meet the needs of women; however, there were capacity issues within the induction of labour suite that sometimes meant low-risk patients waiting several hours for induction of labour. Timely advice and support via the telephone triage line was not always available. Leadership within maternity inpatient services was good overall and staff spoke highly of managers with the exception of those in the labour ward. Midwives working in this area found it difficult to raise concerns because doing so was not always met with a positive response. In addition, staff working in this area reported that staff meetings felt punitive in nature and that staff who were involved or witnessed serious incidents were not always well supported. Risks were managed satisfactorily and performance was monitored appropriately, but action was not always taken, or monitored, to address issues highlighted during audits.

Surgery (gynaecology)

Good

Updated 22 May 2015

Surgical services at Liverpool Women’s Hospital were caring, effective, responsive and well-led. There were some concerns about the comprehensiveness of patient records, medical handovers, medicines management and storage, safeguarding practices and levels of staff training, which meant that safety required improvement. There were processes and procedures used in practice both pre and postoperatively to ensure that people received good care and treatment that resulted in a short hospital stay. Systems were in place to monitor the quality and performance of the various wards and areas, and these resulted in actions to improve care when necessary. Staff had access to the information they needed to deliver care to their patients. Patients reported that staff were kind and patient, protecting their privacy and dignity while providing a high level of care and support. The gynaecology service responded to the needs of the local population by providing services where gaps had been identified. Joint working with other organisations had also resulted in improved access to services for patients. Staff were proud of working at the trust and described a culture of openness in which they could discuss concerns or ideas with the managers.

Termination of pregnancy

Good

Updated 22 May 2015

There were robust systems for the reporting of incidents and the management of risk within the Bedford Centre. The centre was visibly clean, medicines were safely stored and well managed, and the standard of record keeping was good. There were sufficient well-trained nurses to provide safe and effective care.

The multi-disciplinary team worked well together, using national guidelines to treat patients. Access to information was good and there were robust processes in place to gain consent.

Services were delivered by caring and compassionate staff who treated patients with dignity and respect. Care and treatment was planned and delivered in a way that took into account the wishes of the patient.

Access to treatment, advice and information was good both during procedures and after discharge. Complaints were well managed. The trust’s vision and values for the organisation had been well communicated to staff.

There was a ‘no blame’ culture

that gave staff confidence to report incidents and ‘near misses’.

We saw individual members of medical and nursing staff who displayed good leadership skills and were positive role models for staff generally.

Neonatal services

Good

Updated 22 May 2015

We found that, overall; the neonatal services provided were good. There was a sense of pride in the service and staff were committed to providing high-quality services. Neonatal nurses and doctors worked well together to achieve the best outcomes for the babies in their care. Babies received high quality care from dedicated and caring staff who were highly skilled in working with newborn babies and their families. There was a robust system in place for reporting and learning from incidents. The unit was visibly clean with a well-managed, clearly understood approach for maintaining a suitable environment. The standard of record keeping was good and both the nursing and medical staffing levels were appropriate to meet the needs of the babies in the unit. The multidisciplinary team worked well together. There were clear evidence-based guidelines to support practice. The service had achieved level 3 baby friendly status and there was focused work by staff to improve breastfeeding rates. Parents were active partners in the care of their babies, and communication with parents and families was good. Services were delivered by staff who were caring and considerate. Parents were universally positive about the care their babies had received and provided us with examples of when staff had ‘gone the extra mile’ to care for their babies and support them at the same time. Staff were proud to work in the unit and passionate about the service they provided. They were keen to receive feedback from families and the results were clearly displayed on a noticeboard. Feedback was used to support service developments. The service received very few complaints but had dealt with the ones they had received in an appropriate manner. There was access to a translation service for parents and families, and information available in different languages. There was a transitional team and an outreach team that helped babies to be discharged home at the earliest opportunity. The services provided by the unit were well-led. There was strong medical and nurse leadership. Senior staff were positive role models for staff, and were visible and accessible. Staff were supported and encouraged to be innovative in their practice. There were robust governance systems in place. We saw good examples of a positive ‘no-blame’ culture and a well-developed approach to learning.

End of life care

Good

Updated 22 May 2015

Patients who were considered to be in the last year of life were cared for in one of two specialist end of life suites on wards within the hospital (whenever possible). The Mulberry and Orchid suites were part of gynaecology ward 1 and provided patients with a private and calm environment where they could be cared for in an appropriate and tranquil setting. Patients and those close to them valued the environment and some patients had chosen the suites as their preferred place to die. The specialist palliative care team responded to the needs of patients in a timely way and were accessible to ward staff for support, advice and mentoring. There was good multidisciplinary working for the benefit of patients. Staff participated in regional and national networks to support service development and improvement. Staff were caring and compassionate and there was evidence of individualised, person-centred care. Processes for rapid discharge were in place to allow patients to return quickly to their preferred place of care. However, we did not see robust evidence of advanced care planning and ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) decisions were not always made in a timely way so that patients could be involved in the decision making.

Outpatients

Good

Updated 22 May 2015

There was good practice in the outpatient and diagnostic imaging departments to promote the safety of patients and staff. 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. Cleanliness and hygiene in the department were of a good standard. Regular hand hygiene audits showed an appropriate level of compliance. Patient records were generally available for clinics although there were occasions when they were not. It was not possible to ascertain how widespread the issue was because incidents that related to the availability of patients’ notes were not reported consistently and the availability of notes was not audited. Staff and managers could not tell us the percentage of notes that were unavailable. The issue was recorded on the risk register a week before the inspection started. Staff were aware of the policies and procedures to protect and safeguard children and adults, and training statistics showed that most staff had completed training in safeguarding for both children and adults. Other mandatory training courses were well attended and staff were positive about the training provided. They had also been trained in managing major incidents. Staffing was generally good; however, there were occasions when the foetal medicine unit was understaffed and managers were looking at ways to resolve this. The diagnostic imaging department used a private provider for sonography to address staff shortages. There was no evidence at the time of our inspection that this was having an impact on patient safety.