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Royal Albert Edward Infirmary Requires improvement

We are carrying out checks at Royal Albert Edward Infirmary using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 September 2017

The Royal Albert Edward Infirmary is a large district general hospital operated by Wrightington, Wigan and Leigh NHS Foundation Trust. It provides a full range of hospital services including emergency care, critical care, general medicine (including elderly care), surgery, neonatal care, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services. The hospital has 513 beds.

Urgent and emergency services and children and young people’s services at Royal Albert Edward Infirmary were previously inspected in December 2015. Urgent and emergency services were rated as ‘good’ and children and young people’s services were rated as ‘requires improvement’.

In March 2017, we carried out an unannounced inspection of these services to review specific areas of care including the assessment and observation of patients, record keeping, pathways of care for discharging or transferring patients, staff training and staffing levels.

The inspection was in response to concerns that were raised about the safety of services provided to patients. The inspection therefore focused solely on the safety of services provided. We inspected the hospital during the evening/night of 17 March 2017, visiting the following areas:

  • Paediatric Emergency Care Centre (PECC)
  • Emergency Care Centre (ECC)
  • Rainbow Ward

We found that these services required improvement for safety. This was because the systems and processes for recognising risks and escalating the deteriorating patient were not always adhered to, records were not always completed correctly and compliance levels in some areas of training, such as safeguarding level three, were lower than the trust target.

Our key findings were as follows:

  • Records were not always completed fully by medical and nursing staff. This meant there was limited evidence of the care provided to patients.

  • Despite tools being available to help staff manage risks to patients, they were not always used effectively. For example, in some records we reviewed we saw no evidence of clinical observations, early warning scores and risk assessments. We also had concerns that some of the guidance relating to managing risk was unclear. For example, one piece of guidance instructed staff to complete ‘routine’ observations, without clarifying the specific frequency.

  • Mandatory training figures for staff did not always reach the trust target of 95%. Training for safeguarding was particularly low. This posed a risk that staff may not have the necessary training to enable them to care for patients appropriately.

  • Dispensers storing sanitising gel were empty in the main reception area in the emergency care centre. This limited people’s ability to clean their hands effectively prior to entering the department.

  • A room in the emergency care centre storing major incident and chemical decontamination equipment was also used occasionally to take blood samples from patients. The room was a less than ideal environment with large items of equipment next to the trolley where patients sat to provide their samples.

  • Duty of candour was not fully documented in the investigation report following the never event on Rainbow ward.

  • Appropriate action was not always taken following completion of the Paediatric Early Warning Score (PEWS) on Rainbow ward.

    However:

  • Following our inspection in December 2015, the trust had improved the levels of training for nurses on Rainbow ward, with higher compliance in advanced paediatric life support and tracheostomy care.

  • Staffing levels on Rainbow ward were also improved, with greater numbers of staff available to care for children at all times.

  • Staff in the Emergency Care Centre were able to explain their actions during major incidents or incidents involving hazardous substances.

In areas of poor practice the trust needs to make improvements.

Importantly, the trust must:

  • Ensure staff complete mandatory safeguarding children training appropriate to their role.
  • Ensure staff complete other mandatory training to maintain compliance in line with the trust target.
  • Ensure that tools to manage risk are used and recorded such as completing risk assessments and observations and taking appropriate action when triggering Paediatric Early Warning Scores (PEWS).
  • Ensure that patient records are accurate and complete.

In addition the trust should:

In relation to children and young people services:

  • Ensure duty of candour is documented following a notifiable safety incident.
  • Ensure cleaning schedules are consistently completed in all areas.
  • Ensure the expiry date is legible on all controlled drugs.
  • Ensure the medicine fridge thermometer is reset in line with trust policy and action taken is documented when the fridge temperature deviates from the acceptable range.
  • Ensure the refrigerator in the milk room is available and fit for use.
  • Ensure current guidelines for the management of paediatric sepsis are available for staff.

In relation to urgent and emergency services:

  • Ensure trust guidance is consistent throughout all departments in relation to the use of early warning scores, clinical observations and general monitoring of patients, and that where required, categories and frequency of monitoring is stipulated to ensure clarity.
  • Ensure that all staff use the same guidance relating to the frequency of observations
  • Ensure that sanitising gel is available in all dispensers
  • Review the suitability of the room used to store major incident equipment in relation to taking blood samples from patients
  • The trust should review the entrance and exit door to the paediatric emergency care centre with a view to ensuring the risk of children or young people exiting the department is as low as practicable.
  • Consider amending the checklists used on resuscitation trolleys to ensure any action to replace missing items can be documented to avoid potential confusion.
  • Consider introducing checklists to record that defibrillators have been checked rather than relying on printed strips stored in no particular order.
  • Obtain assurance and ensure that staff involved in assessing patients are aware of, or appropriately prompted to consider female genital mutilation
  • Ensure that guidance about conditions requiring senior medical review covers occasions when consultants are not on site and available only on an on call basis.
  • Ensure that the care pathway for caring for patients with a blood borne virus is up to date and that the latest version is displayed on the relevant noticeboard in the emergency care centre.
  • Only store equipment in appropriate packaging and remove equipment that is not stored in this way.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 14 September 2017

Effective

Good

Updated 22 June 2016

Caring

Good

Updated 22 June 2016

Responsive

Good

Updated 22 June 2016

Well-led

Requires improvement

Updated 22 June 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 22 June 2016

The maternity and gynaecology services at Royal Albert Edward Infirmary (RAEI) required improvement in the safe, effective and well – led domains.

We rated Maternity services at RAEI as ‘required improvement’ in terms of being safe.

Staff knew how to report incidents. Lessons were shared and learned using techniques such as roleplay scenarios that included both midwifery and medical staff, however; there was no integrated trustwide learning system. All areas were visibly clean and tidy and staff followed hygiene procedures.

Safeguarding processes were in place and under review. We found that door entry systems to both the postnatal ward and the delivery suite did not adequately protect patients. We observed some visitors let other people gain access to the unit who had not used the intercom system to identify themselves to staff members.

Medicines were stored in secure cupboards and daily checks completed, however out of date items were identified. On the delivery suite, the controlled drug cupboard was on the open corridor behind the nurse’s station rather than behind a locked door.

There was a lack of assurance about the recording and maintenance of equipment including that used in an emergency. There were ongoing maintenance issues related to sewage coming up through the drains on the maternity unit which had been reported and investigated several times but not resolved. Staff reported that this happened on a monthly basis requiring patients in the area to be re-located.

In the maternity unit, we reviewed care records for seven patients and prescription charts for five patients. We found them to be legible and completed appropriately. However on Swinley ward, we found records showed that patient care had not been carried out within expected timescales for a patient whose condition was deteriorating. The processes on that ward to obtain consent for surgical procedures did not always follow best practice guidance.

Midwifery and nursing staff had completed the majority of mandatory training to the trust’s target of 95% with the exceptions of basic life support at 84%. Medical staffing numbers were adequate for the patient needs. Any shortfall in staffing levels was supported by bank nurses; however the monitoring of locums was not robust.

Maternity services at RAEI required improvement in terms of being effective.

Trust guidelines were in place; however these were not always clear or adhered to. However guideline reviews were not robust in that they did not always identify required changes and updates. The trust participated in a number of local and national audits. The national neonatal audit (NNAP) showed that the trust performed below the NNAP standard for four out of five indicators.

Women were assessed for pain relief and supported individually whether in labour or post operatively. There was a choice of meals available and patient’s breast feeding was supported in the wards and in the community. Midwives were annually assessed by their supervisors and other staff had been appraised to be competent. Midwives did not routinely rotate between the various areas which meant there was no formal process to keep all their skills up to date. Services were available seven days a week on the wards; however no routine antenatal or gynaecology clinics were available at RAEI.

Maternity services at The Royal Albert Edward Infirmary (RAEI) were good in terms of being caring.

Patients and their families were positive about their care from the nurses, midwives and doctors. They felt involved, were given good explanations and felt that staff were helpful and kind. We observed staff actively engaging with patients and families in a kind and compassionate way. Patients were accommodated sensitively, where possible, if a side room was appropriate. Emotional support was available if needed.

When in ward bays, with curtains around the beds, conversations were overheard during examinations.

Maternity services at the Royal Albert Edward Infirmary (RAEI) were good in terms of being responsive.

The service had been planned across the geographical location. There were maternity and gynaecology inpatient services, however no routine antenatal or gynaecology clinics onsite. Each maternity patient was allocated a named midwife, both in the community and as an inpatient. The busiest of the antenatal clinics was Thomas Linacre Centre (TLC) that was close to RAEI.

There were specialist midwives including public health, safeguarding and a mental health nurse. In addition, diversity and dementia champions were available. Any patient identified with a learning disability or mental health issue were supported on an individual basis as needed.

Midwives were not clear about the trust vision and strategy. There were regular senior meetings that were cascaded to staff but staff felt that meetings with them needed to be more formal. Staff felt that they were supported by their managers, however hospital midwives felt there were fewer opportunities for them to develop than midwifes in the community.

Medical care (including older people’s care)

Good

Updated 22 June 2016

We found that the Royal Albert and Edward Infirmary was delivering good medical services to patients but some areas of the service, particularly those relating to safety, required improvement.

All staff knew the trust vision and behavioural framework and said they felt supported and that morale was good. All staff were committed to delivering good, compassionate care and were motivated to work at the hospital.

The hospital had implemented a number of schemes to help meet people’s individual needs, such as the forget-me-not sticker for people living with dementia or a cognitive impairment and a red label to indicate that a patient was frail or elderly. This helped alert staff to people’s needs. However, we found on the discharge lounge patients’ privacy and dignity was not always being maintained and this was due to the facilities available not being fully used.

People were supported to raise a concern or a complaint and lessons were learnt and improvements made. Medical services captured views of people who used the services with changes made following feedback. A survey showed that people would recommend the hospital to friends or a relative.

There were governance structures in place which included a risk register. Some actions on the register had no timeframes for completion and it was unclear if these were being managed in an effective way to lower the risk.

There were concerns in relation to nursing staffing on some of the wards during the day and at night, especially on Ince ward and Astley ward. Clinical staff had access to information they required, for example diagnostic tests and risk assessments. However, we found records were left unsecured on the wards we visited and whilst records did include a treatment plan for each patient, there were standards for record keeping that required improvement.

Clinical waste was not always being stored in the designated places and there were concerns over the design of the endoscopy unit leading to the use of the discharge lounge to recover patients. There were also concerns about the decontamination facilities on the unit.

Nursing staff were unclear about the procedures to follow when reaching decisions about using bed rails which are a form of restraint. This was due to the assessment paperwork not including the recording of consent or best interest decisions but staff knew about the key principles of the mental capacity act. Incidents were reported by staff through effective systems and lessons were learnt and improvements made from investigations where findings were fed back to staff. There were systems in place to keep people safe and staff were aware of how to ensure patients’ were safeguarded from abuse. The hospital was clean and staff followed good hygiene practices.

There were a number of patients being cared for in non-speciality beds but there were clear protocols in place to help manage care for these patients. Best practice guidance in relation to care and treatment was usually followed and medical services participated in national and local audits. Action plans were in place if standards were not being met.

Urgent and emergency services (A&E)

Good

Updated 14 September 2017

  • Records were not always completed fully by medical and nursing staff.
  • Despite tools being available to help staff manage risks to patients, they were not always used effectively. For example, in records we reviewed we saw no evidence of clinical observations, early warning scores and risk assessments in some records. We also had concerns that some of the guidance relating to managing risk was unclear.
  • Mandatory training figures for staff did not always reach the trust target of 95%. Training for safeguarding was particularly low.
  • Dispensers storing sanitising gel were empty in the main reception area. 
  • A room storing major incident equipment was also being used to take blood samples from patients. The room was a less than ideal environment.

However

  • There was a culture of reporting and learning from incidents amongst staff.
  • Medicines were managed, stored and checked correctly with automatic systems in place.
  • Staff were 100% compliant in mandatory training topics including anti-fraud awareness, emergency planning, conflict management and dementia training.
  • Major incident information was clearly displayed for staff, who were supported by a trust policy.
  • All the areas we reviewed were visibly clean and tidy. Cleaning schedules were used and adhered to.
  • The right equipment was available for staff caring for patients.

Surgery

Good

Updated 22 June 2016

Overall, we found that the Royal Albert Edward Infirmary delivered ‘Good’ surgical services.

Staff were committed and proud of the services they provided. Staffing levels were sufficient and a safer nursing care staffing tool was utilised to ensure staffing levels were adequate. Medical staff rotas were in place and locum agency staff filled any gaps when the service was short staffed. Staff morale was good and staff felt well supported.

Incidents were reported and lessons learnt shared amongst staff. Staff knew how to access the incident reporting system and could tell us about incidents they had reported. There were low incidents of pressure ulcers and infections. Risk assessments were completed and staff implemented measures to reduce risks.

The environment was clean and tidy and staff had access to the equipment they required to do their jobs. Medicines were managed safely and stored securely.

Referral and discharges worked well and staff shared relevant information. Services worked in coordination and patients were appropriately referred to specialist services. Staff treated patients with respect and dignity, offered support and included them in care planning. Patients received a caring service and staff discussed treatment plans with patients to ensure a person-centred approach.

The trust 18 week referral to treatment times were similar to or above the national average of 90% for all surgical specialities except general and oral surgery. WWL is in the top 10% nationally for RTT performance as at October 2015, ranking 5th out of 139 Acute Trusts.

Risk registers were in place and discussed at team meetings. Staff were aware of the trust’s values and vison. Staff felt well-supported by managers and colleagues.

Intensive/critical care

Good

Updated 22 June 2016

We rated the critical care services at the hospital as good. This was because patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises. The staffing levels and skill mix was sufficient to meet patients’ needs. Patients were supported with the right equipment. Patients received care and treatment by trained multidisciplinary staff that worked well as a team.

Medicines were stored and administered appropriately. However, fridge temperatures were not always maintained below 8ºC. Staff minimised the risk to patients by taking additional steps such as reducing the expiry date of medicines stored in the fridges.

The services provided care and treatment that followed national clinical guidelines and staff used care pathways effectively. The services performed in line with expected levels for all performance measures in the Intensive Care National Audit and Research Centre (ICNARC) 2013/14 audit. This meant the majority of patients had a positive outcome following their care and treatment.

There was sufficient capacity to ensure patients could be admitted promptly and receive the right level of care. Bed occupancy levels were consistently lower than the England average. The number of out-of-hours discharges, delayed discharges and patients transferred out for non-clinical reasons were within expected levels when compared to other critical care units nationally.

The relatives of patients spoke positively about the care and treatment provided. Patients were treated with dignity, empathy and compassion. Staff involved patients or their relatives in their care and supported them with their emotional and spiritual needs.

There were systems in place to support vulnerable patients. Complaints about the service were shared with staff to aid learning. There was effective teamwork and clearly visible leadership within the department. Staff were positive about the culture within the critical care services and the level of support they received from their managers.

Services for children & young people

Requires improvement

Updated 14 September 2017

  • There was one never event reported by the trust on Rainbow ward between 1 March 2016 and 31 March 2017.
  • Duty of candour was not fully documented in the never event investigation report.
  • Compliance rates for safeguarding children level three was 77.8% for paediatric medical staff and 28.6% for registered paediatric nurses on Rainbow ward.
  • Records we reviewed showed that four out of five records did not have appropriate actions taken on triggering Paediatric Early Warning Score (PEWS).

However,

  • Staff knew how to report incidents and lessons learned were shared with staff
  • The ward was visibly clean and staff adhered to current infection prevention and control guidelines.
  • Emergency resuscitation equipment and safety testing was in place, and a bedrails assessment was completed on admission.
  • Safeguarding policies and procedures were in place across the trust. Staff we spoke with were aware of their roles and responsibilities and knew how to raise matters of concern appropriately.
  • The nursing staff ratio on Rainbow ward was a maximum of 1:5 for both general paediatric patients and paediatric surgical patients. Between 1 January and 31 March 2017, this had been achieved on all but four shifts (98.5%).

End of life care

Outstanding

Updated 22 June 2016

We found that there were good EOL services across all five domains of Safe, Effective, Caring, Responsive and Well Led.

Incident reporting systems were in place and actions were followed up at ward level via handover. There had been no recent serious incidents related to EOL care. Anticipatory EOL care medication was prescribed appropriately and training for the use of syringe drivers was included in mandatory training for which the SPC team were 100% compliant. EOL services were adequately staffed and as well as the SPC team which was clinically led by a consultant in palliative medicine, there was a bereavement specialist nurse, a gold standards framework (GSF) facilitator and two EOL champions on each ward.

There was evidence of the service delivering treatment and care in line with best practice, including the individual plan of care (IPOC) document which facilitated support for the dying person in the last days and hours of life. The service was starting to implement the gold standard framework (GSF) and had appointed a facilitator to introduce and embed this in the two pilot wards. We saw that the service had made changes to their practice to address some of the targets not met in the last National Care of the Dying Audit of Hospitals (NCDAH), May 2014 and there was evidence that some actions were in place as a result of other clinical audits however there were not always action plans in place which met the criteria for being specific, measurable, achievable, realistic and timely (SMART). This meant there was a potential risk that some recommendations or findings from audits may not be translated into actions in a timely manner or may be missed altogether.

We saw evidence that pain relief and nutrition and hydration needs for patients were being met. The SPC team provided a seven day service and worked well, across all the hospitals, with other teams and disciplines.

EOL care services were provided by compassionate, caring staff who were sensitive to the needs of seriously ill patients. The service was delivered by staff who were committed to providing a good service and there was good clinical leadership from a consultant in palliative medicine. There was a coordinated approach across the Wigan borough to design EOL services to meet the needs of the local population. There were systems in place to prioritise EOL patients for side rooms at RAEI and this was working well. Facilities and systems were in place to minimise stress for families staying with their EOL relatives and to allow them to spend as much time as they wished with them in their last days and hours. This included the use of the swan logo which identified EOL patients and their families, enabling staff to treat them accordingly.

The visibility of senior management was good and staff felt well supported and there was an open door policy by senior staff.

Areas for improvement included completion of uDNACPR forms which were inconsistent in their quality. An action plan should be developed to address the shortcomings identified in the trust’s uDNACPR audit.

Outpatients

Good

Updated 22 June 2016

We found the services of the outpatients and diagnostic imaging to be good overall. Patients had clear access to the clinics and radiology, though car parking was an issue. Areas were visibly clean and waiting times for appointments were short. The departments had sufficient staff and where shortfalls existed there were plans in place to ensure continuous service. There was some weekend clinics and acute radiology services was open 24 hours a day. The outpatient waiting area was dated but the new cancer centre, opened in January 2015, was bright and spacious in comparison.

Staff at Royal Albert Edward Infirmary told us they were proud of where they worked and would recommend it as a workplace and a place to treat their family. Staff training was up to date and the trust encouraged learning. Incidents and errors were treated as a learning opportunity to keep patients safe in the future. Patients told us that staff were caring and compassionate and they were given sufficient information about their treatment.

The management were visible and approachable to staff. Audits to assess the departments were continuous and innovation and change was promoted. Staff felt supported by the managers.