St Helens and Knowsley Teaching Hospitals NHS Trust was formed in 1991 and is now a £309m provider organisation, providing care to a population of 350,000. The services are provided across the boroughs of St Helens, Knowsley, Halton and the area of South Liverpool. The Mersey Regional Burns and Plastic Surgery unit at Whiston Hospital provides treatment for patients across Merseyside, Cheshire, Isle of Man and parts of the North West.
The trust has 887 beds and employs over 4,000 members of staff.
A full range of acute services is provided across two sites;
Whiston Hospital provides a comprehensive range of services including an urgent and emergency care facility, general and specialist medicine, general and specialist surgery full consultant led obstetric and paediatric hospital service for women, children and babies.
St Helens Hospital provides a range of hospital services, including general and specialist medicine, general and specialist surgery outpatients and diagnostic testing.
We carried out this inspection as part of our scheduled program of announced inspections.
We visited the both locations on the 19-20-21 August 2015. We also carried out an out-of-hours unannounced visit to Whiston hospital on Saturday 5 September 2015.
Our overall rating for this trust was Good.
We found that the trust provided services that were outstanding for caring and of good quality, responsive, effective and well-led.
Our key findings were as follows:
Leadership, vision and values
The trust’s mission was ‘to provide high quality health services and an excellent patient experience’. The trust’s vision for ‘five star patient care’ was supported by five key areas: safety, pathways, systems, care, and communication. The vision was also underpinned by the ACE behavioural standards; Attitudes, Communication and Experiences.
The vision, values and behavioural standards were clearly displayed throughout both hospital sites and it was evident from our discussions and interviews with staff that they were fully engaged in their ongoing development and implementation.
The trust was led and managed by a stable, visible and accessible executive team. The senior team led the trust with a consistent focus on service quality and positive patient experience.
Patient safety and positive experiences were key priorities for the Trust and underpinned all aspects of service planning and delivery.
The Trust achieved the vast majority of national targets across the full range of services provided.
The executive and non-executive directors were very well known to staff and were frequent visitors to the wards and departments on both hospital sites. There were positive levels of staff engagement. Staff were highly motivated and committed to providing high quality services and experiences for patients. The trust had been ranked as one of the top 100 places to work by a Heath Service Journal in both 2014 and 2015.
The Trust also positively engaged with both patients and the local community. There was a range of inclusion events provided for the local community. The CEO was very visible and highly regarded within the local area.
There was a very positive culture throughout the trust. Staff were positive about their line managers and felt supported, able to raise concerns, suggest improvements and develop professionally. Staff were proud of their services and proud of the trust.
There was a range of reward and recognition schemes that were highly valued by staff. Staff were supported and encouraged to be proud of their service and achievements.
The Employee of the Month award was discussed at all board meetings and staff felt valued by the high profile this award had within the organisation.
The annual awards ceremony was a focal point for staff who were very positive about the evening as an opportunity to celebrate theirs and their colleague’s achievements. Successes at all levels were actively acknowledged and celebrated.
However, in maternity services there were concerns regarding the visibility and the lack of a proactive approach from service leaders. Staff also raised concerns regarding a lack of transparency about the management of the service. These included a lack information sharing by the management team and a lack of opportunity to discuss and understand the services strategic objectives.
In maternity, staff felt well supported by their immediate line managers, however, felt there was a lack of senior support for innovation and limited opportunities for them to be proactive about service development. This was the only service where we found this to be the case.
Governance and risk management
The trust had good systems and processes for governance and risk management. A comprehensive system was in place that set out the roles and responsibilities for risk management.
The Board Assurance Framework (BAF) was aligned to the trust vision, values, objectives and priorities. Controls, mitigation, assurance, gaps in assurance, rating and rationale for ratings were clearly documented. The BAF linked appropriately to the corporate risk register that was regularly reviewed.
Mortality rates
The Trusts mortality rates compared with the England average and there were robust systems and processes in place to review mortality and share learning as appropriate.
Nurse Staffing
Nurse staffing establishments were calculated using a recognised dependency tool and regularly reviewed. There were minimum staffing levels set for all wards and departments. All the wards and departments had adequate staffing numbers at the time of our inspection. However, the maintenance of nurse staffing levels remained a challenge for managers. This was a particular issue in Maternity, Medicine and Gynaecology services at Whiston Hospital. Staffing levels were maintained by staff regularly working overtime and with the use of bank or agency staff.
There was an escalation process in place that nurses used to alert managers to staffing shortages (often as a result of unplanned absence). Managers responded by securing additional resources where possible to maintain appropriate staffing levels and skill mix. Staffing levels were discussed at ‘bed meetings’ and contingency arrangements were applied to meet increased demand in areas with high patient acuity.
The trust maintained a rolling programme of nurse recruitment that meant vacancies were filled in a timely way. In addition the trust had implemented a number of initiatives to address shortages in nurse staffing including: actively recruiting nursing staff from overseas and linking with local universities.
Midwifery Staffing
Maternity staffing did not comply with the Royal College of Obstetrics and Gynaecologists recommendations of the safer childbirth staffing standards. This was identified on the maternity risk register and had been reviewed annually and proposals for improvement presented to the executive team since 2013. This situation had been reviewed by the board in June 2015 with resulting agreement to recruit five midwives and five midwife support assistants. This additional recruitment meant that the service would then meet national guidance in respect of staffing levels.
Medical staffing
Although there were a number of medical vacancies patients received prompt and appropriate medical intervention.
Medical staff rotas were maintained by the existing staff and through the use of agency or locum consultants. Where locum doctors were used, they were subject to recruitment checks and induction training to ensure they understood the hospital’s policies and procedures. The majority of locum and agency doctors had worked at the hospital on extended contracts so were familiar with the hospitals management systems and expectations.
There was ongoing consultant and middle grade recruitment and there were plans in place to appoint an additional specialist palliative care consultant to enhance and strengthen the service provided to patients.
There was a well-established standing operating procedure for the review of patients placed in wards outside the required speciality (outliers). There was good evidence that this (small) group of patients were reviewed on a daily basis.
Access and flow
The trust met internal and national referral to treatment targets and was meeting the national six week target for patients waiting for a diagnostic appointment. The trust also performed better than the England average during 2013/14 and 2014/15 for patients waiting less than 32 and 62 days for treatment. We found the trust was consistent with the England average for patients seen by a specialist within two weeks from 2013/14 to 2014/15. Patients were provided with diagnostic tests and treatment in a timely way. Performance in this regard was above the national average.
Discharge planning began at the point of admission and there were processes in place to facilitate timely discharge seven days a week. As a result the number of delayed dischrges were reducing.
The emergency care pathway had been under considerable pressure due to increased demand. The proportion of all patients that attended the emergency department and were treated within four hours was 93.2% (2,099 attendances) between October and December 2014, 91.7% (2,548 attendances) between January and March 2015 and 93.2% (2118 attendances) between April and June 2015. This level of performance was just below the national target of 95%. There was an action plan in place to improve performance in meeting the four-hour waiting time targets. This included actions to review medical staffing arrangements to improve treatment and discharge times and to improve medical cover during nights and weekends.
There were also occasions when the handover of patients from ambulance crews was not completed in a timely way. However, since January 2015, the emergency department had set up a rapid assessment and treatment (RAT) process where a consultant was allocated at set times on a daily basis to assess and treat ambulance stretcher patients. This had led to a reduction in the number of ‘black breaches’ and improved performance in this area.
In addition, There were escalation plans in place in the event of increasing system pressure and demand on the bed base. However, there were times when patients were placed in areas not best suited to their needs and condition. The systems in place for the medical review and treatment of these patients were robust and well understood by staff. There was evidence that this group of patients were appropriately reviewed on a daily basis.
Cleanliness and Hygiene
Patient-led assessments of the care environment (PLACE) showed that the trust has achieved the best PLACE audits nationally for two consecutive years 2014 and 2015.
Both hospitals were visibly clean. Cleaning schedules were in place with clearly defined roles and responsibilities for cleaning the environment and decontaminating equipment. Staff were aware of and followed current infection prevention and control guidelines.
Regular hygiene audits indicated a high level of compliance throughout the trust.
The numbers of MRSA and MSSA infections were below the England average between April 2013 and March 2015. C.diff infections were within expected limits. Infection control training had been completed by 95% of staff.
Nutrition and hydration
Wards throughout the trust had protected mealtimes when all activities on the wards stopped, if it was safe for them to do so. This meant staff were available to help serve food and assist those patients who needed support.
Patients who required support and assistance with eating and drinking were identified using a coloured jug system. Support to patients was provided in a sensitive and discreet way.
Patient records included assessments of patient’s nutritional requirements; fluid and food charts were reviewed and updated regularly.
Specialist dieticians were involved in with patients who were identified as needing a special diet or support.
We saw several areas of outstanding practice including:
- The trust had developed a pressure ulcer (PU) risk assessment tool used by the tissue viability nurses across the wards. This took into account the grade of the PU risk and a care plan was determined which included the equipment to be used for the patient.
- The additional needs pathway and coordinated approach to a patient with additional needs reduced the need for repeat procedures and enhanced the patient’s experience.
- In order to improve the response time and access to timely treatment for a patient, if a critical or abnormal finding on an X-ray was seen detected radiology staff could book another follow up appointment with the appropriate specialist at the time of reporting.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Continue its efforts to meet four-hour emergency department national targets.
- Meet the DH target for handovers between ambulance and emergency department.
- Ensure there is the appropriate skill mix of staff and patient’s privacy and dignity is maintained at all times on the coronary care unit.
- Ensure there is a system in place to assess and improve the quality and safety of the services provided following a serious incident. This must include actions to mitigate the risks relating to the health and safety of service users. (Maternity services).
- Ensure systems in place for the storage of medicines are safe.
Professor Sir Mike Richards
Chief Inspector of Hospitals