Archived: Royal Liverpool Site

Updated 17 July 2019

The Royal Liverpool University Hospital is a large teaching hospital based in Liverpool and is one of two hospital sites managed by the Royal Liverpool and Broadgreen University Hospitals NHS Trust (the trust). The Royal Liverpool University Hospital is one of the largest hospitals in Merseyside and Cheshire, based close to the city centre, providing care and treatment to patients from across the North West of England, North Wales and the Isle of Man.

The Royal Liverpool University Hospital is the main site operated by the trust, with a total of 857 beds, 792 of which are inpatient beds and 65 are reserved for day case procedures. This hospital provides a range of services, including urgent and emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, and a range of outpatient and diagnostic imaging services. The hospital also houses St Paul’s Eye Unit which provides a range of outpatient services and elective and unplanned ophthalmology surgical services to patients locally, nationally and internationally. The unit sees in the region of 9,000 outpatients each month.

The hospital was last inspected in March 2016 and was rated as good overall.

We reviewed information provided to us before, during and after the inspection, including patient records. We spoke with staff of different grades, including registered and unregistered nurses, doctors and managers of different roles and levels.

We also spoke with relatives and patients to help us understand what they thought of the care and the treatment that they had received.

Updated 17 July 2019

• The hospital had not always ensured that risk assessment for patients, such as falls or pressure ulcers and been completed.

• There had not always been sufficient numbers of staff on wards or suitable qualified staff available in endoscopy to recover patients.

• Controlled substances that were hazardous to health had sometimes been left in unlocked areas, meaning that patients or members of the public could access them. In addition, oxygen cylinders had not always been stored safely, in line with best practice guidance and trust policy.

• Services had not always collected, analysed, managed and used information well to support all its activities. This was because information that was provided before, during and after the inspection had not always been accurate.

• Staff did not always understand how and when to assess whether a patient had capacity to decide about their care. We found that capacity had not always been documented when needed.

• Medication and controlled drugs were not securely stored or prepared in line with trust policy, national guidance and legislation.

• Waiting times in the emergency department had all risen and were greater (longer or more) than the national average.Patients waited for extended periods of time on the corridor to be seen, in some cases more than ten hours.

However:

• The hospital managed infection prevention and control well, the results of infection prevention and control audits were scrutinised and improvements to practice made.

• Services had effective arrangements in place to recognise and respond appropriately to patients

• Staff understood how to protect patients from abuse and the service worked with other agencies to do so. Staff received training in safeguarding.

• Managers across services promoted a positive culture that promoted and valued staff, creating a sense of common purpose based on shared values.

• Staff cared for patients with compassion and that patient’s dignity was maintained on all occasions that we observe

Updated 29 July 2016

Staff experienced difficulty managing their caseloads at busy periods and this was exacerbated by a high sickness rate. However, the trust had plans in place to improve recruitment. There were higher than average incidents of falls with harm than would be expected. Overall, mandatory training rates were below the trust’s target. High bed occupancy and low discharge rates placed pressure on the system to the extent that there were often times when beds were unavailable, resulting in patients sleeping in the assessment room. Staff used a range of risk assessment tools to ensure patients received the right level of care for their acuity in line with national guidance and best practice. Staff were knowledgeable in the procedures for safeguarding patients and staff reported incidents appropriately. Care was delivered that was kind, compassionate and ensured patient dignity was maintained. Patients were well informed and felt their input was valued when planning their care and treatment. Staff understood the vision and values of the service and there was a clear leadership structure in place. Monthly performance meetings were held and relevant issues were communicated effectively to staff.

Updated 29 July 2016

There were sufficient numbers of suitably skilled nursing and medical staff to care for the patients. We found a culture where incident reporting and learning was embedded and used by staff. There was strong clinical and managerial leadership at unit and divisional level. The unit had a vision and strategy for the coming years developed in accordance with the building of the ‘New Royal’ on the adjacent site. There was an effective governance structure in place which ensured that all risks to the service were captured and discussed. The framework also enabled the dissemination of shared learning and service improvements and a pathway for reporting and escalation to the trust board. Patients and their relatives were cared for in a supportive and sympathetic manner and were treated with dignity and respect. There were issues with access and flow within critical care, which were related to the wider access and flow pressures within the hospital. These regularly resulted in delayed discharges and the associated cancellation of elective surgery.

Updated 29 July 2016

Palliative care was considered integral to the trust and had a well-developed and substantial palliative care directorate which was part of the medicine division. The trust had an embedded strategy for end of life care driven by effective leadership and delivered by committed staff who were highly satisfied with their workplace. Staff frequently went ‘above and beyond’ to deliver compassionate, high quality care that took into account patient’s wishes. The service was complemented by a strong volunteer body who offered respite and emotional support, ensuring no patient died alone. The service was designed with consideration given to the needs of the local population, and the trust adopted a multidisciplinary approach with input from a variety of external stakeholders to ensure joined up continuity of care. End of life care audit data showed the trust performed excellently, scoring above the national average for each of the seven indicators. Staff were competent to perform their roles and received regular training to ensure competence was monitored and maintained. Medicines and other equipment were stored and monitored regularly to ensure patient safety. The service was well staffed, and had 86 link nurses across the trust to educate, advise and support colleagues in end of life care on every ward. Incidents were reported and investigated appropriately by knowledgeable, trained staff and all learning was shared.

Updated 29 July 2016

Policies and procedures were in place for the prevention and control of infection and to keep people safe. Care provided was evidence based and followed national guidance. Staff were competent to perform their roles and worked together in a multi-disciplinary environment to meet patients’ needs. Care that was planned took account of patients’ wishes, and psychological and emotional support was available in a number of outpatient clinics. Patients had a choice of appointments and additional clinics were held in the evenings or at weekends to reduce waiting times. Between May 2015 and February 2016 the trust met the national standard for diagnostic imaging waiting times with the exception of January 2016. Quality and performance were monitored and there was evidence of continuous improvement and innovation.

Updated 17 July 2019

• The service managed infection prevention and control well, the results of infection prevention and control audits were scrutinised and improvements to practice actively sought.

• The service had effective arrangements in place to recognise and respond appropriately to patients needs and risks.

• The service planned for emergencies and staff understood their roles if one should happen.

• When incidents were reported, the service investigated them thoroughly and used the information to improve the service.

• The service used best practice guidance to inform the delivery of care and ensured treatment was based on evidence based practice.

• The service managed nutrition and pain well.

• Staff within the service demonstrated high levels of commitment to patient care. Staff treated patients with kindness, dignity and respect. Feedback in relation to patient care was consistently positive.

• The service planned and delivered care based on the identified needs of both the immediate community and wider community it served.

• Staff were proactive in their approach to establishing the individual needs of patients.

• The service was well led by effective and enthusiastic managers, who were aware of risks to the service and were capable of tackling difficult issues head on, of making advancements and gaining staff commitment to improvement.

  However:

• Both premises and equipment were tired and not always well kept and maintained effectively.

• Controlled drugs were not securely stored in line with trust policy, national guidance and legislation.

• Medicines including patient own medications and antibiotic medication were not always checked, recorded and reviewed in line with trust policy and best practice guidelines.

• Patients often endured prolonged periods within recovery areas following surgery due to bed capacity and flow issues within the wider hospital.

Updated 17 July 2019

• Patients did not always have completed or updated risk assessments within the emergency triage area in line with its trust policy or national guidance.

• Medicines were not consistently stored securely or prepared in line with national guidance.

• Mandatory training levels for medical staff below the specified standard.

• Patient outcome data from national audits such as the Royal College of Emergency Medicine was below the expected standard and non-planned re-attendance rate within the department was higher.

• The total time patients spent within the department, the median time to treatment, patients leaving the department without being seen and patients reattending within seven days had all risen and were greater (longer or more) than the national average. Patients waited for extended periods of time on the corridor to be seen, in some cases more than ten hours.

  However,

• Staff had a clear awareness around safeguarding and female genital mutilation, training levels for safeguarding were high and a clear referral pathway was in place.

• Staff kept accurate records of patients care and treatment.

• Training levels for mental health act and mental capacity act awareness was high within the department and staff knew how to assess and suitably refer patients suffering from mental health illness.

• Staff treated patients with kindness, empathy, dignity and respect.

• The department provided services in a way that met the needs of the local populations in the way of a virtual clinic, a consultant telephone service and an integrated community re-enablement assessment service.

• Leaders with the department were both visible and approachable and staff felt supported within their role