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Halton General Hospital Requires improvement

We are carrying out checks at Halton General Hospital 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 27 November 2017

Halton General Hospital is one of three locations providing care as part of Warrington and Halton Hospitals NHS Foundation Trust. It provides non-complex, elective surgery and a range of outpatient services. There is a minor injuries unit (open 9am to 10pm every day) which provides a range of minor emergency care services, and the hospital provides x-ray facilities until 8pm. There is a step down ward for patients who have had surgery or emergency medical care but who require some further support before going home. There are chemotherapy services on site and the hospital is home to the Delamere Macmillan Unit, which provides cancer support and advice. The site is also home to a specialist orthopaedic facility the Cheshire and Merseyside NHS Treatment Centre (CMTC).

The CMTC is a standalone operating and clinical facility for orthopaedic surgery services across the trust. Warrington and Halton Hospital NHS Foundation Trust provides services across the towns of Warrington, Runcorn (where Halton General Hospital is based), Widnes and the surrounding areas. It provides access to care for over 313,500 patients.

We carried out an announced inspection of Halton General Hospital as part of our comprehensive inspection of Warrington and Halton NHS Foundation Trust.

Overall we rated Halton General Hospital as Requires Improvement.

We found that services were provided by dedicated, caring staff and patients were treated with dignity and respect. However, we found improvements were needed to ensure that services were safe and well-led.

Our key findings were as follows:

Incidents:

  • There was individual feedback to staff members following an incident and then feedback to all staff by email and through the safety briefing. The nurse manager said that some of the older staff didn’t like to report incidents but the nurse manager had shown how improvements had been made in the department as a result of reporting incidents. One of the issues was that other departments in the hospital were bringing patients to the Urgent Care Centre (UCC), this was inappropriate and as a result of raising incidents the practice was stopped.

  • The trust reported low numbers of surgical site infections (SSI) following surgery. Between April 2015 to April 2016, there had been four incidents of SSI in knee replacement surgery and three incidents of SSI in hip replacement surgery. SSI’s were monitored by the orthopaedic department in-line with National Institute for Health and Care Excellence (NICE) guidelines for quality standards for orthopaedic surgical site surveillance. The surveillance information collected during April 15 to March 16 showed there had been 672 hip and knee operations and indicated that the orthopaedic joint replacement infections were minimal and mainly superficial infections. This indicated that care and treatment was being delivered with high regard to infection prevention procedures.

  • The Duty of Candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. There was a trust wide policy and Duty of Candour process in place. Staff we spoke with had an awareness of the need to be honest when things go wrong although they could not fully describe the requirements of the regulation. Senior staff understood the principles of the Duty of Candour.

Cleanliness and infection control

  • The trust had infection prevention and control policies in place which were accessible to staff.

  • The areas we visited were visibly clean and tidy. Patients told us areas were clean and that staff washed their hands which reflected what we saw.

  • There was access to personal protective equipment such as aprons and gloves and we saw staff using this equipment appropriately to prevent the risk of the spread of infection. Decontamination procedures were followed in line with best practice in endoscopy.

Environment and equipment

  • Daily morning surgical meetings were held to ensure that all staff had the required equipment for the surgeries planned for that day. We observed in theatres staff checking and setting surgical instruments. The check was verbal and visual between two staff in-line with standards and recommendations for safe practice.

Medicines:

  • There were patient group directives (PGD’s) available for specific nurses to give patients appropriate pain relief. PGD’s allow healthcare professionals to supply and administer specified medicines to pre-defined groups of patients. This helps patients to access medicines in a safe and timely manner and PGD’s were audited by the department. There was a competency framework for those nurses covered by the PGD. Each nurse had their own prescription pad with a dedicated log of the patient’s number, the details of the script and the signature of the nurse prescriber. These logs were checked daily to ensure that the numbers of logs tallied with the number of scripts dispended.

  • Staff in some outpatient areas used patient group directions (PGD’s) to administer medicine without a doctor, such as eye drops or contrast media. The procedures and staff competencies were inspected and complied with standards.

  • There were arrangements in place for managing medicines and medical gases. Nursing staff were able to explain the process for safe administration of medicines and were aware of policies on preparation and administration of controlled drugs as per the Nursing and Midwifery Council Standards for Medicine Management. We saw that there was an up to date policy for the safe storage, recording of, administration and disposal of medicines. This was available for staff on the intranet.

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Nurse staffing:

  • The Urgent Care Centre (UCC) used the emergency severity index (EMS) as an acuity tool to determine the staffing of the department and they had received additional funding for staffing from the clinical commissioning group.

  • Within the Outpatient and Diagnostic department, nursing staff worked between Halton and Warrington sites, covering and responding to change in staffing needs on a day-to-day basis as necessary. Rotas were planned ahead according to clinic demands and staff worked flexibly to cover this.

  • We saw staffing in theatres met the Association for Perioperative Practice (AfPP) safe staffing guidelines. This ensured that there were adequately trained staff to provide safe surgical care to patients. We saw from the surgical procedures we attended that there was appropriate staffing levels for each theatre.

Medical staffing

  • A resident medical officer (RMO) was based at Halton Hospital 24 hours a day, seven days a week on a rotational basis.

  • There was a doctor present in the UCC department from 8am to 10pm. A consultant from Warrington urgent and emergency care department held a weekly clinic in the department.

  • There were four GP’s who worked in the department. Three of the doctors did one day each and the other doctor worked for four days. The doctors worked from 8am to 10pm. They covered for each other during holiday periods and so there was little use of locum cover

  • On-call senior medical support was available outside of core working hours. Nursing and medical staff confirmed that they were able to access senior medical support if required.

Leadership and Management

  • The senior team, in the majority of core services, were visible and accessible and well known to the staff.

  • The urgent and emergency care department had undergone a change in leadership early in 2016 with the clinical business unit (CBU) model brought in. The trust had used assessment centres and other management tools to identify leaders in the potential applicants for the clinical and nurse leads for the CBU. The CBU had a clinical lead who was a consultant anaesthetist, a lead nurse and a manager. Both of the clinical staff had come from outside of the department. Since the implementation of the CBU, performance in the department had shown marked and ongoing improvements in safety and performance. This was due to the leadership in the department which was robust and the senior staff led by example.

Access and Flow

  • The urgent care centre, saw between 2,500 and 3,000 patients every month, these numbers had more than doubled since the reconfiguration from a walk in centre to an urgent care centre.

  • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the urgent and emergency care centre. In the period from March 2016 to December 2016 the department had consistently achieved over 99%.

  • Between October 2015 and November 2016, the average length of stay for surgical elective patients was better at the trust at 2.7 days, compared to 3.3 days for the England average.

  • Halton hospital had a shorter length of stay across both elective and non-elective admissions than both the trust and the England average.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards:

  • Data showed that of December 2016, 67% of medical staff and 78% of nursing staff had completed their Mental Capacity Act (MCA) training. Staff we spoke with understood the legal requirements of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) in order to protect patients appropriately.

  • The service accepted children and young people less than 16 years of age and were able to prescribe emergency contraception. Staff were aware of Gillick competencies and Fraser guidelines. They also said that they would raise a safeguarding referral if appropriate.

We saw several areas of outstanding practice including:

  • The public engagement work at the urgent care centre was innovative using the local rugby league clubs to promote the appropriate use of services on their website with You Tube videos.

  • The trust 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 medicine.

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

Importantly, the trust must:

In Medicine:

  • The trust must ensure that staff receive training on the Mental Capacity Act (2005) and that staff work in accordance with The Act.

In Surgery

  • The trust must take action to provide and maintain an assurance system that World Health Organization (WHO) checklists are completed appropriately as to the standard operating procedure.

  • The trust must take action to provide and maintain an assurance system that all anaesthetic machines are checked in line with trust policy.

  • The trust should take action to provide and maintain an assurance system that all stocks are within their expiration date.

  • The trust should take action to improve the number of suitably qualified staff in advanced life support in recovery.

Outpatients & Diagnostic Imaging:

  • The trust must take action to ensure that all safety and quality assurance checks are completed and documented for all radiology equipment, in accordance with Ionising Radiations Regulations 1999.

  • The trust must take action to ensure equipment is safely maintained at all times, with repairs completed in a timely way.

  • The trust must ensure all appropriate infection control measures, including environmental cleaning, are observed in all diagnostic and treatment areas, with consistent records

In addition the trust should:

In Emergency Department:

  • Flagging of patients with a learning disability or those who require special adjustments for their treatment.

  • Provide a waiting area for children and young people that is separate to the main waiting room.

  • A registered children’s nurse available on every shift at the centre.

  • Ensure the closure of the low scoring risks on the risk register.

In Medicine:

  • The trust should ensure that the required processes and procedures are in place to safely deliver treatment on the planned investigation unit.

  • The trust should ensure that staff on the planned investigation unit, receive appropriate training and work within their competence level.

  • The trust should ensure that mandatory training and appraisal levels improve.

  • The trust should ensure that governance systems are operated effectively at clinical business unit and divisional level.

  • The trust should ensure that risk registers are complete and are reviewed regularly with evidence of the outcome of review.

  • The trust should ensure it seeks feedback on medical services at the hospital from patients and the public.

In Surgery:

  • The trust should take action to improve staffing levels across wards and theatres.

  • Although mandatory training performance has improved since the last inspection. The trust should take action to improve their mandatory and clinical skills performance across all core areas.

In Outpatients and Diagnostic Imaging:

  • The trust should ensure all patient case note records are maintained in a complete and chronological order, with accurate details of follow up for patients who did not attend appointments.

  • The trust should ensure patients receive sufficient, clear and appropriate information regarding their hospital appointment. This should include adequate directions to clinic locations and relevant written information about treatment plans where this is indicated.

  • The trust should ensure departmental risk registers are clearly identified and recorded, with implementation and monitoring of associated action plans

  • The trust should ensure directorate communications are in place to provide staff with appropriate support and inform staff regarding departmental arrangements

  • The trust should consider actions to improve child-friendly aspects of waiting room environments in outpatient departments.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 27 November 2017

Effective

Good

Updated 27 November 2017

Caring

Good

Updated 27 November 2017

Responsive

Good

Updated 27 November 2017

Well-led

Requires improvement

Updated 27 November 2017

Checks on specific services

Medical care (including older people’s care)

Good

Updated 27 November 2017

At our last inspection in January 2015 we rated medical services as good. We have maintained the overall rating following this inspection because:

There were systems in place to ensure risks to patients were minimised. Staff completed risk assessments and records were completed fully and accurately. The environment was visibly clean and staff followed infection prevention and control best practice including strict decontamination procedures in endoscopy.

Nursing staffing and medical cover was generally adequate to meet the needs of patients although there were times when nursing staffing fell below the expected level.

Medicines were stored appropriately and checks were carried out regularly on essential emergency equipment.

However:

There was open access to clinic areas where clinical supplies and medical records were stored. On PIU, trolleys were stored unsupervised in the bay areas with clinical supplies such as needles, cannulas and sterile water for injection.

Basic life support training for the acute care division was below the trust target. Safeguarding rates for medical staff were also below the trust target.

Urgent and emergency services (A&E)

Good

Updated 27 November 2017

We rated urgent care services as good  because:

The urgent care centre had processes in place to reduce the risk of harm to patients. There was learning from incidents and staff had been trained to appropriate safe-guarding levels.

Staff worked to guidance from the National Institute of health and Care Excellence (NICE) and compliance was audited. There was multi-disciplinary working and staff were competent. The department was meeting the Department of Health target for the four hour wait.

There was strong leadership and there were governance structures in place that supported the work of the department.

Staff were caring and there was good feedback from patients about the work of the department.

Minor injuries unit

Good

Updated 10 July 2015

Systems were in place for reporting and managing incidents. There was a risk-aware culture in the department and a willingness to learn from mistakes. Patients received care in safe, clean and suitably maintained environments with the appropriate equipment. Staff were aware of their role in safeguarding and could escalate concerns about abuse and neglect appropriately.

There were sufficient numbers of suitably trained staff to provide the service for patients. Staff worked well together as a multidisciplinary team for the benefit of patients. National guidance was used to provide evidence-based care and treatment for patients. Patients were assessed for pain relief as they entered the unit.

Staff treated patients with dignity, compassion and respect. Patients spoke positively about the care and treatment they had received. Staff provided patients and those close to them with emotional support and comforted patients who were anxious or upset. Staff were confident and competent in seeking appropriate consent.

From April 2014 to December 2014, the service met the national Department of Health target to admit or discharge 95% of patients within four hours of arrival. Key risks and performance data was monitored regularly and remedial action taken when performance shortfalls were identified. A trust-wide complaints and concerns policy included information on how people could raise concerns, complaints, comments and compliments, but we noted complaints about the service weren’t always closed in a timely manner.

There was clearly defined and visible leadership within the service and staff felt free to challenge any staff members who were seen to be unsupportive or inappropriate in carrying out their duties. Staff were proud of the work they did and worked well together for the benefit of patients.

Surgery

Good

Updated 27 November 2017

At the previous inspection in January 2015, we rated this service as good. Following this inspection we have maintained the overall rating because:

We found there was a good culture of incident reporting in order to learn and share good practice.

Mandatory training compliance across the division had improved following the last inspection and although training in all areas was not above the trust target, improvements were evident.

All floor areas and bed spaces on the surgical wards we visited appeared visibly clean. We saw cleaning schedules were signed and dated to show that areas were clean.

We saw that patient records were structured, legible, complete and up to date and contained risk assessments and care plans that were individualised to the patient’s needs.

Staff could identify and respond appropriately to changing risks to patients, including deteriorating health and wellbeing or medical emergencies.

Pain scores were regularly recorded, and patients informed us that they were offered appropriate pain relief. The trust’s referral to treatment time (RTT) for the percentage of patients seen within 18 weeks was 76.9%, which was better than the England average of 71.5%.

However:

We found that the anaesthetic machines were not always being checked in accordance with the Association of Anaesthetists for Great Britain and Ireland (AAGBI). Daily checks of anaesthetic machines should be recorded daily. This was highlighted to the theatre manager immediately to ensure compliance.

We saw on two occasions that the World Health Organization (WHO) checklist in surgery was not followed fully.

We observed that in one surgical procedure, no formal introductions of the team were completed in the ‘time out’ section of the checklist.

In another surgical procedure, the anaesthetist was not present for the identification check at the ‘sign in’ section of the checklist. The WHO checklist is designed to eliminate the occurrence of surgical errors when followed correctly and requires all staff to take part. Since March 2016 there had been three never events relating to surgical procedures at the Halton site. Two of these never events occurred in March 2017. ‘Never Events’ are serious, largely preventable patient safety incidents, which should not occur if the available preventable measures have been implemented by healthcare providers.

In recovery, we saw that national guidance was not being adhered to ensure there were enough suitably qualified recovery nurses on shift with advanced life support training. Although there were formal audits completed, that included infection control, we saw no evidence that managers had a formal system or process of oversight, that ensured the cleanliness of equipment, and system checks were maintained.

However, during the unannounced inspection we saw that the service managers had reacted quickly to our concerns, and new systems and processes implemented with management oversight to ensure compliance with standards and policy.

Outpatients

Requires improvement

Updated 27 November 2017

 We have rated the service Requires Improvement because:

The service monitored referral to treatment times continually. Times were consistently better than the England average, except for urology, ophthalmology and paediatric orthopaedics. Waiting times for referral and treatment for cancer were better than the England average.

The service audited practice well to maintain standards. Radiography staff had received an award for a research paper from the UK Research Council. Staff were caring and showed understanding in communicating with patients. Administrative, nursing and medical staff took care to show their patients respect and protect their dignity. Patients consistently gave positive feedback about staff.