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Warrington Hospital Requires improvement

We are carrying out checks at Warrington 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

We carried out an announced inspection of Warrington Hospital  between the 7 and 10 of March 2017. In addition, we carried out an unannounced inspection between 3pm and 9pm on the 23 March 2017. This inspection was to follow up on the findings of our previous inspections in January and February 2015, when we rated the trust as requires improvement overall. We also looked at the governance and risk management support for all of the core services we inspected.

At this inspection we inspected the following services at Warrington Hospital:

  • Urgent and Emergency Care

  • Critical Care Services

  • Services for Children and Young People

  • Maternity and Gynaecology Services

  • Medical Services [Including the care of older people]

  • Surgery

  • End of Life Services

  • Outpatient and Diagnostic Services

As part of this inspection, CQC piloted an enhanced methodology relating to the assessment of mental health care delivered in acute hospitals; the evidence gathered using the additional questions, tested as part of this pilot, has not contributed to our aggregation of judgements for any rating within this inspection process. Whilst the evidence is not contributing to the ratings, we have reported on our findings in the report.

We rated Warrington Hospital as requires improvement overall with Medicine [including older people’s care] Critical Care, Outpatient and Diagnostic services and Maternity and Gynaecology Services as requires improvement. We rated Urgent and Emergency , Surgery, End of Life Services and Services for Children and Young People as good.

There had been progress since our previous inspection with, improvements noted in urgent and emergency care, maternity, surgery, outpatient and diagnostic services  and Critical care. However, Warrington Hospital continues to require improvement in key areas.

Our key findings were as follows:

  • Systems had been put in place to improve access and flow through the Accident and Emergency department and although targets were not been met there had been a continuous improvement in waiting times.

  • The trust monitored the number of cancelled operations on the day of surgery. Performance data showed that the number of cancelled operations on the day of surgery had improved from 11.9% in February 2016 to 8.8% in January 2017.

  • The National Paediatric Diabetes Audit 2014/15 showed that Warrington hospital performed better than the England average for the number of individuals who had controlled diabetes.

  • There had been some improvements since our last inspection in January 2015: working relationships between medical staff and midwifery staff, overall culture was improving, WHO checklist and consent forms, laparoscopic hysterectomies were undertaken and mandatory training for nurse and midwifery compliance rates had improved.

We saw some areas of outstanding practice including:

  • The trust had developed the Paediatric Acute Response team to deliver care in a Health and Wellbeing Centre in central Warrington. This allowed children and young people to access procedures such as wound checks and administration of intravenous antibiotics in a more convenient location. It also allowed nurse-led review of a range of conditions such as neonatal jaundice and respiratory conditions in a community setting that would have previously necessitated attendance at hospital.

  • Within the urgent and emergency care division, the use of the Edmonton frailty tool in the treatment of older people in the department and the wider health economy.

  • The training of all the consultants within the accident and emergency department in the use of ultrasound for timely diagnosis of urgent conditions.

  • 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.

  • The environment on the Forget Me Not ward had been designed using the recommendations set out by The Kings Fund to be dementia friendly. The ward was designed to appear less like a hospital ward and featured colour coded bay areas and a lounge and dining area designed to look like a home environment. There was access to an enclosed garden and a quiet room. 

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

Importantly, the hospital must:

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

  • The hospital must ensure that paper and electronic records are stored securely and are a complete and accurate record of patient care and treatment.

  • The hospital must ensure that staff receive the appropriate level of safeguarding training.

  • Critical care services must improve compliance with advanced life support training updates and ensure that there is an appropriately trained member of staff available on every shift.

  • The hospital must ensure that the formal escalation plan to support staff in managing occupancy levels in critical care is fully implemented.

  • The hospital must ensure that there are appropriate numbers of staff available to match the dependency of patients on all occasions.

  • The hospital must ensure that all risks are formally identified and mitigated in a timely way as part of the risk management process.

  • The hospital 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.

  • The hospital must ensure midwifery, nursing and medical support staffing levels and skill mix are sufficient in order for staff to carry out all the tasks required for them to work within their code of practice and meet the needs of the patient.

  • The hospital must ensure all necessary staff completes mandatory training, including Level 3 safeguarding training.

  • The hospital must ensure that the assessment and mitigation of risk and the delivery of safe patient care is in the most appropriate place.

  • The hospital must review the impact of the triage system on access and flow and the appropriate assessment of patient safety.

  • The hospital must review the safety of the induction bay environment to ensure patient safety is maintained at all times and that the premises are safe to use for the purpose intended.

  • The hospital must ensure that all staff receives medical devices training and this is recorded appropriately.

  • The hospital must ensure that that the risk register and action plans are comprehensive, robust and adequate to improve patient safety, risk management and quality of care.

  • The hospital must ensure staffing levels are maintained in accordance with national professional standards.

  • The hospital must ensure that there is one nurse on duty on the children’s unit trained in Advanced Paediatric Life Support on each shift.

In addition the trust should:

  • The hospital should ensure that the mandatory and safeguarding training rates are monitored for medical staff.

  • The hospital should consider that the urgent and emergency care department make improvements to the room used to see patients with mental health problems, particularly to the doors so that they open outwards.

  • The hospital should make reasonable adjustments for appropriate patients including those with a learning disability.

  • The hospital should improve appraisal rates for nurses and medical staff.

  • The hospital should consider that the Early Pregnancy Assessment Unit (EPAU) is opened seven days a week.

  • The hospital should identify ways to improve multidisciplinary attendance at local and divisional meetings.

  • The hospital should consider the safe storage of patient’s notes on the wards.

  • The hospital should consider the dignity and privacy of patients within the clinical areas and maternity theatre.

  • The hospital should review accommodation on wards where patients are at the end of their lives. To allow them to supported in rooms that afford privacy for the patient and families.

  • The hospital should review access to specialist palliative care medical support out of hours.

  • The hospital should continue to review compliance with DNACPR policy and clear application and documentation of mental capacity assessments.

  • The hospital 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 hospital 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.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 27 November 2017

Effective

Requires improvement

Updated 27 November 2017

Caring

Good

Updated 27 November 2017

Responsive

Requires improvement

Updated 27 November 2017

Well-led

Requires improvement

Updated 27 November 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 27 November 2017

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

Although staffing levels had improved since the last inspection, adequate staffing and skill mix remained an issue within the service.

Shift leaders on the labour ward and other wards within the division, were often not supernumerary due to staffing levels and workload.

There was no dedicated Triage area or Triage team in the maternity unit.

The induction bay area was an inadequate and unsafe environment for patients and had an adverse effect on staffing levels on the maternity ward.

Due to medical staffing levels and access and flow issues, there were often delays in patients being admitted, reviewed and /or discharged from hospital.

Outlier patients posed access and flow issues on the gynecology ward.

There were no established transitional care facilities available for babies on the maternity wards.

There was no dedicated obstetric staff for the daily elective caesarean section list. This led to cancellations and delays in treatment and care.

The maternity services did not have a current robust data collection system, such as a maternity dashboard, to benchmark and review clinical and quality performance outcomes and implement clinical changes to improve patient care.

The risk register did not provide assurance that action plans were comprehensive, robust and adequate to improve patient safety, risk management and quality of care, as many risks were static in their ratings.

The service did not record staff competencies for medical devices training.

Patient records were not securely stored in locked trolleys.

We observed a patient experiencing a sensitive procedure in a six-bedded bay in a gynaecology 

ward. This was due to access and flow issues but also highlighted that the needs of the individual were not met.

Staff informed us that senior trust leadership were “still slightly reactive” in their management style, even though this had improved recently. Senior management told us that the organisation tended to focus on displays of compliance and safety after incidents and events had taken rather than anticipating and mitigating risks to improve the quality of care.

Not all staff were clear on the future strategy for maternity services.

However:

There had been some improvements since our last inspection in January 2015: working relationships between medical staff and midwifery staff, overall culture was improving, WHO checklist and consent forms, laparoscopic hysterectomies were undertaken and mandatory training for nurse and midwifery compliance rates had improved.

The appointment of the new Head of Midwifery had a positive effect on staff and the future of the service.

The Alongside Midwifery Led Unit (AMU) was in its early stages of development but there was a real focus on normal labour and birth.

The service had recently relaunched the Maternity Services Liaison Committee (MSLC) with a newly appointed chair.

Staff were caring, kind and patient and were committed to providing good care to patients.

Medical care (including older people’s care)

Requires improvement

Updated 27 November 2017

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

There were times when there were insufficient registered nurses to care for patients. There were high numbers of medical staff vacancies and agency use was high.

Patients did not always receive timely medical intervention, for example in cases of sepsis.

Medical handovers were unstructured and medical notes did not always contain sufficient information about patient care and treatment.

Mandatory training rates for medical staff, including safeguarding training, were all below trust target. Appraisal rates were also below the trust target.

Patients were at risk of being unlawfully deprived of their liberty or receiving care and treatment without consent to because staff did not follow the trust Mental Capacity Act procedure.

Governance systems were not sufficiently embedded within the acute care division. The risk register was not effectively managed to show how risks to patients or the service were being reduced. Complaints were not always responded to in a timely way.

However:

Care was provided in line with best practice by multi-disciplinary teams who worked well together.

Patient outcomes were generally good and the trust met the national target for treatment waiting times.

Staff were kind, caring and compassionate and understood the emotional needs of their patients.

The Forget Me Not ward was designed to meet the needs of patients living with dementia and staff provided individualised care for this patient group.

Staff were positive about the leadership and culture of the service.

Urgent and emergency services (A&E)

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:

On arrival at the hospital, patients were triaged to the most appropriate department to meet their needs. Appropriate risk assessments were in place to protect patients and analgesia for pain relief could be administered to patients. Patients were monitored using appropriate tools and any deterioration in a patient’s condition would be escalated.

There were processes in place to help to keep people safe, incident reporting was good and infection control measures were in place. Medicines were administered to patients in a timely way and there were regular checks of equipment. The nurses had reached the trust target for mandatory training.

Treatment and pathways for patients were developed using national and local guidance and was delivered by competent staff working in multi-disciplinary teams. There were review structures in place so that treatment was up to date and these were monitored by the staff.

Staff were caring and supported patients and their relatives and carers. Privacy and dignity were maintained at all times. Systems had been put in place to improve access and flow through the department and although targets were not been met there had been a continuous improvement in waiting times.

Governance structures were robust and there was strong leadership in the department. Staff were empowered through development and learning opportunities and morale in the department was good.

However:

The department was not meeting Department of Health 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.

The department was not meeting the targets for time to initial assessment (emergency ambulance cases only) which should be less than 15 minutes and the time patients should wait from time of arrival to receiving treatment is no more than one hour.

There was insufficient medical cover at night in the department though this had been addressed by the unannounced inspection.

Doctors had not completed their mandatory training. Appraisals for nurses and doctors had not been completed.

The mental health room in the department was not fit for purpose and needed to be improved.

The department needed to work better with patients with learning disabilities to understand their needs.

Reasonable adjustments needed to be made for appropriate 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.

Serious incidents were investigated fully to establish the root cause, and lessons learnt were shared with staff to avoid reoccurrence.

All clinical areas and bed spaces on the surgical wards we visited appeared visibly clean and cleaning schedules were maintained.

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

Mandatory training compliance for nursing staff across the division had improved following the last inspection.

We saw that the service took part in a range of local and national audits and results were discussed at clinical audit meetings and actions for further improvements identified.

All patients and relatives we spoke with told us that that all members of staff treated them with dignity and respect.

We observed many positive interactions between staff and patients during our inspection. We saw that staff were professional and friendly and created a relaxed friendly environment.

Patients we spoke with were very positive about the way staff treated them.

Patients and those close to them told us that they were involved in planning and making decisions about their care and treatment.

Bed meetings took place four times a day to ensure flow was maximised across the hospital.

The trust monitored the number of cancelled operations on the day of surgery. Performance data showed that the number of cancelled operations on the day of surgery had improved from 11.9% in February 2016 to 8.8% in January 2017.

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.

There were a number of specialist nurses within the trust to help support the care and treatment of patients.

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%.

There was 24-hour medical cover on site to attend to patients who had deteriorating needs.

Senior managers were clear on their strategy to provide high quality services for patients, which included working collaborative within the organisation, and in partnership with other trusts to deliver high quality services.

We saw that Local Invasive Standards for Invasive Procedures (LocSSIP’s) had been developed in partnership with the North West theatre network. The standards were in place to ensure high quality, safe care and treatment for all patients.

However:

We found not all theatre equipment was clean. However, we saw on the unannounced inspection that all theatre equipment appeared clean and new cleaning schedules introduced with oversight provided by managers.

We found some omissions in the completion of daily checks such as resuscitation equipment, anesthetic machines and controlled drugs. However, we saw on the unannounced inspection that new anesthetic logbooks were in use, and daily checks recorded and, controlled drugs and resuscitation equipment had been checked.

We found in theatres that not all stock ready for use was within its expiry date. For example, on the emergency airways trolley the suction catheter and flexible tracheal tube introducer commonly known as a bougie had passed its expiry date.

Vacancy rates for nurse staffing was variable across the wards. All staff we spoke with reported this as a concern and often meant they needed to move wards to provide safe staffing levels.

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 ward staff had knowledge of capacity assessments and best interests meetings, we saw no evidence in three applicable records that this had been applied for those patients who were unable to consent to care and treatment.

Theatre lists did not always run on time due to there not always being available beds for patients post operatively.

Data provided by the trust showed that between September 2016 to December 2016 there were 1180 medical outliers on surgical wards. This number of medical outliers impacted on the number of available beds for surgical patients on the surgical wards.

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.

September 2016 to December 2016, there were 1180 medical outliers on surgical wards. This number of medical outliers impacted on the number of available beds for surgical patients on the surgical wards.

Intensive/critical care

Requires improvement

Updated 27 November 2017

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

We were not assured that critical care services were able to provide a member of staff who was up to date with advanced life support training on every shift. Advanced life support training for adults and children was not provided for any nursing staff. Additionally, only 55% of medical staff and 79% of acute response team staff had completed training updates.

At the time of inspection, there was limited evidence that sufficient controls were in place to prevent the service exceeding full capacity. This was because critical care services were not currently using a formal escalation policy.

There were several occasions when the service had been unable to provide appropriate numbers of nursing staff to match the dependency of patients.

Critical care had an informal vision and strategy to improve the services provided. However, we found that this plan was not documented in either departmental documentation or in the divisional business plan. This meant that we were unsure how the strategy was being monitored and measured.

We found that appropriate actions had not always been taken in a timely way to mitigate the level of risk for those which had scored highly. Additionally, there were a number of risks that had not been formally identified.

The critical care unit had struggled to meet the standard set by the Department of Health in managing mixed sex accommodation appropriately. We saw examples of this during the inspection.

Records indicated that between January 2016 and December 2016, there had been 75% delayed discharges (greater than four hours following the decision being made that a patient is fit for discharge to a ward).

However:

The unit used a combination of best practice and national guidance to determine the care that they delivered. These included guidance from the National Institute for Health and Care Excellence (NICE) and the Intensive Care Society (ICS).

The most recently available and validated ICNARC data (April 2016 to September 2016) showed that the patient outcomes and mortality were similar to benchmarked units nationally.

Staff treated patients in a caring and compassionate way; maintaining their privacy and dignity at all times. Both relatives and patients were positive about their time in the unit and spoke highly of the way in which they had been cared for.

Staff informed us they felt that there was an open and honest culture within the department. We observed all team members working well together during the inspection.

Services for children & young people

Good

Updated 27 November 2017

Staff could demonstrate the process to report incidents.

The wards and clinical areas were visibly clean. Staff were aware of and adhered to current infection prevention and control guidelines such as the ‘bare below the elbow’ policy.

Staff were aware of their safeguarding roles and responsibilities and knew how to raise matters of concern appropriately.

Paediatric consultants who took part in a “Consultant of the week” rota were present in the hospital during times of peak activity.

Age dependant pain assessment tools were in use in the children’s unit and analgesia and topical anaesthetics were available to children who required them.

The National Paediatric Diabetes Audit 2014/15 showed that Warrington hospital performed better than the England average for the number of individuals who had controlled diabetes.

Staff were observed treating patients and their relatives with kindness and respect both in person and on the telephone. Facilities were available for parents to stay with their children.

Specialist nurses were in post in a range of specialities including Epilepsy and Diabetes and provided support to young people transitioning to adult services.

A Child and Adolescent Mental Health Services (CAMHS) worker was present in the paediatric emergency department between 5pm and 11pm seven days per week to ensure timely assessment of children and young people.

The Paediatric Acute Response Team (PART) worked with a local community trust to reduce the need for children and their families to attend hospital.

Data from the trust showed 90.5% of patients referred to paediatric services were seen within the 18-week standard.

There was no dedicated paediatric pharmacist for the children’s unit which is not in line with accepted best practice. There was not always a nurse on duty on the children’s unit with Advanced Paediatric Life Support (APLS).

Staffing within the children’s unit did not follow Royal College of Nursing (RCN) standards (August 2013) and neonatal nurse staffing did not meet standards of staffing recommended by the British Association of Perinatal Medicine (BAPM).

Adult areas were children were seen with the exception of ophthalmic clinic, lacked any child friendly decoration or activities.

End of life care

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:

Since our last inspection the hospital specialists palliative care team (HSPCT) had reviewed the strategy for end of life care and had undertaken a self-assessment structured around the six national ambitions for palliative and end of life care.

We reviewed the trust self-assessment and action plan for ensuring the implementation of the “Ambitions for Palliative and End of Life Care” to improve the provision of better care for patients at end of life. Actions included the development of more leaflets for relatives to improve communication and active engagement in regional audits to ensure the HSPCT is complying with best local and national best practice.

There were systems for reporting actual and near-miss incidents across the hospital which meant the service was able to monitor any risks and learn from incidents to improve the quality of service delivery.

There were sufficient numbers of trained clinical, nursing and support staff with an appropriate skill mix to ensure that patients receiving end of life care were well cared for in all the settings we visited.

Medicines were prescribed, stored and administered safely. Access to medicines for people needing continuous pain relief was available to ensure patient’s pain was managed.

The HSPC team had received mandatory training such as safety and safeguarding in order to maintain the safety of patients.

To meet patients’ needs the HSPC team had developed a training programme for specialist palliative care across the trust with end of life link nurses for each ward to support, advise and educate other ward staff in relation to end of life care.

The HSPC team was adequately staffed, well trained and received regular appraisals.

A care management approach “amber care bundle” was in place when doctors were uncertain whether a patient may recover and were concerned that they may only have a few months left to live. This is an approach to care management used in hospitals when doctors are uncertain whether a patient may recover and are concerned that they may only have a few months left to live. The trust had appointed a designated member of staff who worked within the palliative care team to facilitate implementation across the trust.

The trust participated in the “End of life care Audit: Dying in Hospital 2016”, which replaced the NCDAH. The audit results showed an improvement in end of life care at the trust. Out of 17 clinical and organisational indicators the trust had performed either better than or in line with national average in the majority of the indicators. The trust performed better than the England average for three of the five clinically related indicators. The trust scored particularly well for having documented evidence that the needs of person(s) important to the patient were asked about, scoring 3% compared to the score of 56%.

However:

At our last inspection, we found there was no access to specialist palliative care medical support out of hours. At this inspection, we found this was still the case with no access to out of hour’s specialist palliative care medical support.

Senior managers told us that they had improved access to support and advice through the hospital intranet and the lack of specialist palliative medical support had been identified on the trust risk register.

The trust had commissioned an external audit of the use of the DNACPR policy as well as its own internal audit. Results showed there were a number of occasions, where documentation in relation to DNACPR forms has not been in line with Trust Policy.

Engaging in difficult conversations with patients, family or carers was not always fully recorded within the case notes. Patient’s wishes were not appropriately discussed and recorded, and as a result, they are not treated appropriately We reviewed the action plan which had been put in place to ensure the staff training and monitoring of the DNACPR policy was strengthened.to ensure that the DNACPR’s are completed accurately with the medical rationale for not attempting resuscitation and discussions with patients and family being recorded appropriately.

The lack of a clear mental capacity assessment meant that the service could not be clear how much the patient understood the care they were receiving and it may not have access to reasonable adjustments such as access to specialist support.

We found that patients at the end of their lives could not always be assured of a single room to ensure privacy.

Outpatients

Requires improvement

Updated 27 November 2017

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

The CT waiting area was not suitably designed to keep people safe. The area was too small and lacked equipment that would be required in an emergency. The area lacked also privacy and dignity.

We found three breaches of Health and Safety Executive guidance note PM77 ‘Equipment used in connection with medical exposure’ Regulation 36 where there was no record that the equipment had

been tested and signed back into use following fault repairs in the CT department.

Audit evidence showed poor compliance with the WHO (World Health Organisation) surgical safety checklist in interventional radiology.

We found six separate breaches of Ionising Radiation Regulations 99, regulation 32, which refers to routine quality assurance of equipment used in diagnostic imaging.

Appraisal rates and personal development reviews across the department did not meet the trust target of 85%.

The general outpatient area was difficult to locate with poor signage from the main entrance to the department.

There was a lack of available rooms for counselling patients in the breast screening clinic.

There had been significant changes in the leadership team which had the left the staff feeling disconnected and ensure of the strategy and future vision of the service.

However:

We saw evidence of safe practice within the Outpatient department.

There was evidence of hand hygiene compliance and monitoring with regular audits undertaken across six outpatient locations.

Clinical audits were performed in line with best practice and results frequently shared at a regional and national level.

We saw evidence that staff from several disciplines work together to assess, plan and deliver care and treatment to patients including clinicians and allied health professionals.

Cross-site culture was good and staff reported good collaborative working, staff were happy to move between hospital teams.