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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.

Reports


Inspection carried out on 7, 8, 9, 10 March 2017 and 23 March 2017

During a routine inspection

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 carried out on 27-29 January 2015 and 11 Febrary 2015

During a routine inspection

Warrington Hospital is one of three locations providing care as part of Warrington and Halton Hospitals NHS Foundation Trust. It provides a full range of hospital services including emergency care critical care, general medicine including elderly care, general surgery, orthopaedics, anaesthetics, a level 2 neonatal unit, paediatrics and maternity services. The trust also provides services from Halton General Hospital (including the Cheshire and Merseyside Treatment Centre) and genito-urinary medicine services from Bath Street Health and Wellbeing Centre.

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 500,000 patients.

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

We carried out an announced inspection of Warrington Hospital between 27 and 29 January 2015. In addition an unannounced inspection was carried out between 5pm and 8.30pm on 11 February 2015. As part of the unannounced visit we looked at the management of medical admissions out of hours.

Overall we rated Warrington Hospital as ‘requires improvement’. We have judged the service as ‘good’ for caring and effective. However improvements were needed to ensure that services were safe, responsive to people’s needs and well-led.

Our key findings were as follows:

Access and patient flow

  • Due to the increasing numbers of emergency admissions, there was continual pressure on the availability of beds at the hospital. Bed occupancy in the trust overall exceeded the England average throughout 2014, with bed occupancy levels within the medical division in excess of 100%. This meant that some patients were not always placed in the area best suited to their needs. As a result, the management of patient access and flow across the hospital was of concern and remained a significant challenge for managers.
  • There were also pressures placed on bed capacity by the number of delayed discharges, which meant people were in hospital longer than they needed to be. In critical care, staff told us that there were times when, due to bed pressures within the rest of the hospital, pressure was applied to take more patients than they had the staffing levels to manage. As a result, there were times when patients’ needs outweighed the staffing numbers and skill mix.
  • We also identified concerns relating to the management and utilisation of the theatre recovery ‘stabilisation bay’. The standard operating protocol in place for the stabilisation bay stated that up to two patients could be admitted for a maximum of four hours. However, there were instances when more than two patients were admitted to the bay and they often stayed longer than four hours. In some cases patients were cared for in the stabilisation bay for up to two days. The stabilisation bay was also an unsuitable environment for caring for inpatients. There was no privacy, no facilities for relatives and at times children would be in the same area as adults. Furthermore nurses working in the bay were recovery nurses supported by operating department practitioners. This meant that they didn’t always have the competencies needed for managing critical care patients in the longer term.

Cleanliness and infection prevention and control

  • The trust had six cases of MRSA in the period from April 2013 to September 2014. (The target is zero).
  • The trust’s Clostridium difficile (C.diff) infection rate had mainly been worse than (higher than) the England average since September 2013.
  • Each MRSA and C. diff incident was investigated to identify the root cause. Action plans had been developed to prevent recurrence.
  • However, staff were aware of and applied infection prevention and control guidelines.
  • We observed good practices in relation to hand hygiene, ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.
  • Patients received care in a clean, hygienic and suitably maintained environment.
  • Appropriate equipment was in good supply and was clean and well maintained.

Medical staffing

  • Medical treatment was delivered by skilled and committed medical staff.
  • However, there were not always enough medical staff to provide timely treatment and review of patients, particularly out of hours.
  • There were a high number of vacancies in some areas, particularly the emergency department and medical care.
  • Existing vacancies and shortfalls were covered by locum, bank or agency staff when required. All agency and locum staff had to undertake a local induction before they were allowed to work in the trust.
  • British Association of Perinatal Medicine recommendations for Local Neonatal Unit (LNU) out-of-hours Tier 1 medical cover were not adhered to. Trainee doctors told us they had raised this as a serious concern, but it was not clear what action had been taken as a result. Neonatal nurses also told us that they had concerns related to the level of medical cover at night and weekends.

Nursing staff

  • Care and treatment was delivered by committed staff. However nurse staffing levels, although improved, remained a challenge in some key areas. Vacancies and staff absences were covered by bank staff, overtime and agency staff. Although the wards and departments were suitably staffed at the time of our inspection, covering staffing shortfalls in this way is not a long-term sustainable position. This was acknowledged by the hospital management team who were making continuing efforts to recruit staff both nationally and internationally.
  • Although we found staffing levels were adequate at the time of our inspection, there was no flexibility in numbers to cope with increased capacity and demand, or short notice sickness and absence.

Mandatory training

  • Mandatory training attendance varied across the divisions, but on the whole was below the set target of 85% .

Mortality rates

  • Mortality and morbidity meetings were held weekly at divisional level and were attended by representatives from all teams within the relevant divisions. As part of these meetings, attendees reviewed the notes for every patient who had died in the hospital within the previous week. Any learning identified was shared and applied.

Nutrition and hydration

  • Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team.
  • There was a coloured jug system in place to identify and support patients who needed assistance with eating and drinking.
  • Support was given in a sensitive and discreet way.

Medicines management

  • Medicines were provided, stored and administered safely and securely.
  • Anticipatory prescribing in end of life care was embedded in line with best practice. This meant that pain relief and other medication could be provided in a timely way when a patient’s condition changed.

Areas of outstanding practice included:

  • In 2014, the bereavement service for women and their partners who had lost a baby won the national Butterfly Award for “best hospital bereavement service”.
  • The hospital had a purpose built and highly effective ward for patients living with dementia which was well equipped and staffed. Patients with dementia were assessed and admitted to the ward based on the severity of their dementia.
  • The hospital ran a "Hello, my name is...would you like a drink?" campaign to raise awareness within the service of issues surrounding hydrating patients, the importance of accurately filling in fluid balance charts and the prevention and treatment of patients with Acute Kidney Injury.

However, we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [now Health and Social Care Act 2008 (Regulated Activities) Regulations 2014] and the trust needs to make improvements in these areas.

Importantly, the trust must:

  • Ensure that medical staffing is sufficient to provide appropriate and timely treatment and review of patients at all times, including out of hours.

  • Ensure that medical staffing is appropriate at all times, including medical trainees, long-term locums, middle-grade doctors and consultants.

  • Ensure that nursing and midwifery staffing levels and skill mix are appropriate, particularly in medical care services and maternity.

  • Improve the levels of mandatory training compliance.

  • Improve the rate of appraisals completion.

  • Improve patient flow throughout the hospital to ensure patients are cared for on the appropriate ward for their needs and reduce the number of patient bed moves, particularly in the medical division.

  • Ensure the protocols for the use of the stabilisation bay are followed to ensure patients do not stay there longer than four hours, and that no more than two patients are in the bay at any one time.

In addition the trust should:

In urgent and emergency services:

  • Ensure staff complete the Malnutrition Universal Screening Tool (MUST) for all patients who require one.

  • Ensure all staff in the department have time to take their allocated breaks.
  • Look to improve compliance with the Department of Health target to treat 95% of patients within four hours.

In medical care services:

  • Improve processes in place for providing feedback and learning from incidents and complaints.
  • Review systems in place to ensure essential equipment is replaced in a timely manner.
  • Aim to improve access to seven day services for all disciplines across the medical division.

  • Improve processes in place to ensure risks within the division are clearly communicated to nursing staff. Review the admission process for the GP Acute Medical Unit to ensure patients are appropriately referred to the service.

In critical care services:

  • Take action to reduce the number of delayed discharges.
  • Ensure medical records are fully and appropriately completed, in particular the second daily consultant reviews and regular entries by the parent medical team.

In maternity and gynaecology services:

  • Ensure there is a clear vision and strategy for both midwifery and gynaecology services that is clearly communicated with staff.
  • Improve local leadership in maternity services to ensure a cohesive approach to care delivery between medical and nursing staff.
  • Continue to improve staff engagement.
  • Continue to embed and promote the care of low risk women in line with NICE guidelines.

In end of life care services:

  • The increase in referral rates year on year presented a challenge for the service and the provider should ensure that the specialist palliative care team has the appropriate staffing levels and skill mix to meet the demands on the service.
  • Review its access to specialist medical advice over 24 hours in line with national guidance for end of life care.
  • Review accommodation at ward level to ensure that patients at the end of their lives can be nursed in appropriate rooms that afford privacy for the patient and families.
  • Ensure smooth transition of leadership within the palliative care team.

In outpatients and diagnostic imaging services:

  • Take action to ensure that waiting times for outpatient clinics are improved.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 30 June and 1 July 2014

During an inspection in response to concerns

This was a responsive inspection following a review of information provided to us by the trust in relation to 10 intrauterine deaths.

We had also received concerning information about theatre services for the Warrington and Halton Hospitals NHS Foundation Trust.

In response to the information about the maternity services we liaised with Warrington Clinical Commissioning Group and reviewed the information sent to us which included a review of the investigations that had been undertaken and the root cause analyses completed to identify any common factors. This information also included the decision of the trust to deviate from the National Institute for Health and Care Excellence: 'Intrapartum care: care of healthy women and their babies during childbirth' (NICE) CG55 guidance in relation to the care of low risk mothers during labour.

This inspection was conducted to review the trusts management and safety related to promoting the wellbeing of women at low risk of having their babies at Warrington Hospital. In the course of preparing for this inspection concerns were also raised with us by the Royal College of Midwives.

In relation to maternity services we found that the trust had not adequately reviewed and monitored the risks for women and babies in light of their decision to deviate from NICE CG55 and, midwives were not adequately supported in respect of this change in practice, we found moderate non-compliance with the Health and Social Care Act 2008.

In response to the concerns about the theatre department the trust sent us information which we reviewed before the inspection. This information addressed our concerns and during our inspection of the theatres we found that theatre services at Warrington Hospital were safe and managed in accordance with best practice guidance.

Inspection carried out on 28 January 2014

During a themed inspection looking at Dementia Services

We visited Warrington Hospital on 28th January 2014 and went to the Accident and Emergency Department (A&E), elderly care wards A2, A3, A8 and A9. We also spoke with staff on the wards and departments we visited, observed care being delivered and spoke with patients and family members. We also spoke with members of the Dementia Care Team in the Trust including the medical lead and a dementia specialist nurse. We received further information from the Trust during the inspection. We looked at treatment records for patients and spoke with staff who worked in discharge planning and the hospital social work team.

We looked specifically at the care and treatment of people who were admitted to hospital and had either diagnosed dementias or identified cognitive impairments who may have been admitted to the hospital for a number of reasons.

Most people we spoke with told us that they were happy with the service they received in the hospital. One person told us: “The staff seem very jolly with my relative, and chat with her whilst they make sure she is alright”; “The staff have been very caring and informative about the medical condition and treatment for this” and ‘The staff have been great with him all the time he has been here.” Most care we observed was delivered by nursing staff in a kind and responsive manner. We saw that family members were involved in discussions about their relatives by looking in the notes and by speaking with family members.

We also reviewed comment cards which we had left on the wards mentioned above, the majority of which were positive about the service.

We saw that the hospital had a process to ensure that people with dementia who had different support needs were identified on admission and provided with care and treatment which met their individual needs. We tracked four patient’s pathways through the hospital and found that this was effective. The trust used ‘This is me’ a document which can be filled out and given to staff when a person with dementia goes into hospital and provides a 'snapshot' of the person behind the dementia. The leaflet will help hospital staff to learn about the person's habits, hobbies, likes and dislikes; however there was some variation in the quality and detail of information about people’s social histories and preferences.

Most of the staff we spoke with had received a minimum of one day training specifically related to dementia care and they all spoke positively about this.

There were systems put in place by the provider on a ward and trust-wide level to monitor the quality of dementia care provided.

Inspection carried out on 20 March 2013

During an inspection in response to concerns

We spoke with professionals who frequently used the services of the microbiology laboratory and they said they were more than happy with the service that was provided. They said that they were informed by the lab staff of the test results (as soon as these were available) to help plan the patient care pathway. They found lab staff approachable and supportive.

One person said “Very good, cant think of any mishaps”, “ the turn around time is good“, “there is always someone on the end of the phone to give advice and support”.

There were no serious untoward incidents in the last 12 months, providing assurance of good laboratory practice.

Staff spoken with said that they had adequate staff to meet the needs of the service.

Staff spoken with said “I like the job and people it is a good team”, “ we get good training on the job”, “I am quite happy in my work”, “ this is a nice place to work.”

On examination of documents requested and interviews with some users and staff, it appeared that good laboratory processes were in place and that the laboratory offered a high quality and safe service

Inspection carried out on 23 January 2013

During a routine inspection

During our inspection we spoke with 18 people including patients, relatives and other visitors in various wards and departments. Most of the feedback we received was positive. We heard comments such as “the staff are brilliant, nothing is too much trouble for them”; “I give them 90%”; and staff are marvellous and “staff have been good.” We received very few negative comments about the services. One person felt they had a long wait in the accident and emergency department and another person stated that their food was not always as hot as they liked it.”

Patients we spoke with told us they were always asked for their permission before care or treatment was given. We found that the hospital had robust procedures in place to ensure that the rights of patient’s who did not have capacity to make certain decisions for themselves were protected. Staff members were also aware of the action they would take if they suspected that someone was being abused.

We looked at how the hospital managed medicines for patients and we found that they were managed safely and effectively. We also spoke with 10 staff members who told us that staffing levels were adequate as long as people arrived for their shifts.

We looked at 18 sets of patient records during our visit and we found that they were not always accurate. Senior managers showed us the plans in place to deal with the shortfalls that the hospital had identified. We will check records again at our next visit.

Inspection carried out on 20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 9 August 2011

During an inspection to make sure that the improvements required had been made

Areas visited by Care Quality Commission as part of this review were Accident and Emergency Unit, Clinical Decisions Unit, Urgent Care Centre and ward A1.

People we spoke with on all units were satisfied with the care and treatment they received. They said that staff kept them fully informed of all procedures and treatment and gave them reassurance. Comments made included “the staff are very good”, “staff have been marvellous”, “I know what is happening to me”, “ all very good”, “ staff very informative”, “staff have explained to me what is happening and where I will be sent to next”.

Patients said the food was “good”.

Inspection carried out on 6, 19 August 2010

During an inspection to make sure that the improvements required had been made

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.