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Provider: Royal Liverpool and Broadgreen University Hospitals NHS Trust Good

Reports


Inspection carried out on 15 - 18 and 30 March 2016

During a routine inspection

The Royal Liverpool and Broadgreen University Hospitals NHS Trust provides services across two sites, comprising of three hospitals: the Royal Liverpool University Hospital, Broadgreen Hospital and Liverpool University Dental Hospital. The dental hospital was not inspected as part of this inspection.

The Royal Liverpool University Hospital is the main site operated by the trust, with a total of 857 beds, 792 of which are inpatient beds and 65 are reserved for day case procedures. This hospital provides a range of services, including urgent and emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, and a range of outpatient and diagnostic imaging services. The hospital also houses St Paul’s Eye Unit which provides a range of outpatient services and elective and unplanned ophthalmology surgical services to patients locally, nationally and internationally. The unit sees in the region of 9,000 outpatients each month.

The trust started work on a new Royal Liverpool University Hospital in February 2014 and construction is underway, with the opening planned for 2017. The new Royal will be one of the biggest hospitals in the UK to provide all single en-suite bedrooms on each inpatient ward. There will be 23 wards, including a large clinical research facility and a 40-bedded critical care unit and the new Royal will have 18 state-of-the-art operating theatres. The emergency department will be one of the largest in the North West of England with its own CT scanner and special lifts for patients going straight to the operating theatres on the floor above.

Broadgreen Hospital is the smaller of the two sites operated by the trust and has a total of 98 beds, 58 of which are inpatient beds and 40 are reserved for day case procedures. This hospital provides a range of elective general medicine (including elderly care), elective surgery, day case surgery, and, outpatient and diagnostic imaging services.

The trust was inspected previously in November 2013 and December 2013, then again in June and July 2014. These inspections were conducted as part of the initial pilot phases of our new inspection methodology. No ratings were applied and this is the trust’s first comprehensive inspection as part of our new methodology.

The announced inspection took place between 15 – 18 March 2016. We also undertook an unannounced inspection on 30 March 2016 at both the Royal Liverpool University Hospital and Broadgreen Hospital. As part of the unannounced inspection, we looked at the emergency department, medical care wards, surgical care wards and the Academic Palliative Care Unit (APCU).

Overall we rated Royal Liverpool and Broadgreen University Hospitals NHS Trust as ‘Good’. We have judged the service as ‘good’ for safe, effective, caring and well-led care and noted some outstanding practice and innovation. However improvements were needed to ensure that services were responsive to people’s needs.

Our key findings were as follows:

Cleanliness and infection control

  • The trust had infection prevention and control policies in place which were accessible to staff.
  • Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.
  • ‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.
  • Almost all of the areas we visited were found to be visibly clean and tidy. However, the podiatry room within the Diabetes Centre was noted to have dust on the work tops and behind the examination couch and the refrigerator contained a box with mould on it.
  • Infection prevention and control audits and hand hygiene audits were carried out on a regular basis. These identified good practice and areas for improvement. Key actions were identified to be implemented by staff.
  • Between December 2014 and November 2015, the trust reported a total of 42 cases of clostridium difficile, 26 cases of methicillin-susceptible staphylococcus aureus (MSSA) and two cases of methicillin-resistant staphylococcus aureus (MRSA) infections, which meant that the trust did not meet the national standard.

Nurse staffing

  • The trust used recognised and validated tools to determine the required levels of nursing staff.
  • The majority of areas were staffed with sufficient numbers of suitably qualified nurses at the time of the inspection. However, staffing throughout the medical services had been identified as an issue for the trust. The trust were aware of it and had processes in place to escalate issues with staffing but at the time of our inspection we found some areas were still experiencing issues with capacity and ability to manage the wards with the correct staff mix.
  • The trust had introduced a red flag system with criteria for staff to raise issues, such as ward staffing. This included a contact number for nurses to call if any situation where, based on professional judgement, patient care was deemed unsafe. The system also had set criteria to aid decision making for the nursing staff, for example a shortfall of more than eight hours or 25% of registered nurse time available.
  • Any shortfalls in nurse staffing were generally filled with overtime, bank or agency staff. Matrons attended twice daily staffing huddles to ensure safe levels of nurses on the wards. Staffing was displayed on a live rota using a traffic light system. This included pre-booked staff being allocated to wards as needed.

Medical staffing

  • Medical treatment was delivered by skilled and committed medical staff.
  • The information we reviewed showed that medical staffing was generally sufficient to meet the needs of patients at the time of the inspection.
  • The medical staffing skill mix was sufficient when compared with the England average. Consultants made up 37% of the medical workforce at the trust which was similar to the England average of 39%. There were more registrar group doctors who made up 41% of the medical workforce compared with the England average of 38%. Of the medical workforce, 18% were made up of junior doctors, which was higher than the England average of 15%.
  • There were generally low levels of locum use, with substantive staff preferring to work additional hours to fill any gaps in rotas.
  • The Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance states there should be a minimum of one whole time equivalent (WTE) consultant per 250 beds. The trust employed four WTE consultants at the time of the inspection, which was slightly more than recommended.

Mortality rates

  • Mortality and morbidity reviews were held monthly in most services and bi-monthly in outpatients and diagnostic imaging services. Patient records were reviewed to identify any trends or patterns and ensure that any lessons learnt were cascaded to prevent recurrence. However, these were not minuted in some areas.
  • The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 1 would mean that the number of adverse outcomes is as expected compared to England. A score of over 1 means more adverse (worse) outcomes than expected and a score of less than 1 means less adverse (better) outcomes than expected. Between October 2014 and September 2015 the trust’s score was 1.037, which was within the expected range.
  • Critical care services provided continuous patient data contributions to the intensive care national audit and research centre (ICNARC) which allowed outcomes for patients to be benchmarked against similar units nationally. The most recently validated ICNARC data for the period July 2015 to September 2015 showed that the mortality ratio was within the expected range for comparable units. In addition, for the intensive therapy unit (ITU) the data showed that ventilated patients, patients admitted with severe sepsis and patients admitted following elective or emergency surgery, mortality was similar to or better than similar units nationally.
  • Data for the high dependency unit (8HDU) in the same period showed that for elective and emergency surgical admissions the mortality was better than comparable units. However, for admissions with trauma, perforation or rupture, the mortality were was worse than similar units.
  • Evidence based pathways were in place for common causes of mortality in the trust using the Advancing Quality programme.
  • The renal medicine service had developed a clinical pathway for new dialysis patients. The pathway was designed to address the high 90-day mortality rates by targeting: improved rates of transplantation; better enabling self-care; improved vascular access, better medicines management; earlier access to psychological support.

Nutrition and hydration

  • In all the records we reviewed, a nutritional risk assessment had been completed and updated regularly. This helped identify patients at risk of malnutrition and adapt to any ongoing nutritional or hydration needs.
  • Staff in surgical services managed the nutrition and hydration needs of patient’s well, both pre and post operatively. Patients were given information in the form of leaflets about their surgery and told how long they would need to fast pre-operatively.
  • A coloured tray and jug system was in place to highlight which patients needed support with eating and drinking. In addition, there were special plates to meet individual needs including smaller plates for patients’ who needed to eat small amounts frequently.
  • Staff consistently completed charts used to record patients’ fluid input and output and where appropriate staff escalated any concerns.
  • In order to meet the guidelines for the provision of intensive care services (GPICS) standard for dietetic support the unit should have 0.1 whole time equivalent (WTE) of a dietician per critical care bed. However, the current allocation for critical care was 0.04 WTE per critical care bed.
  • The trust scored about the same as other trusts of a similar size in England for the one question related to nutrition and hydration in the Accident and Emergency (A&E) survey 2014.

We saw several areas of outstanding practice including:

  • The emergency department worked collaboratively with local support groups and charities to provide excellent in reach and outreach services to sections of the local population. This meant patients received the best possible care which met their individual needs.
  • The emergency department’s practice development team provided excellent support and education to the staff within the department. They were responsive and provided tailored training programmes in response to issues identified through incidents and debriefing sessions which ensured that the staff within the department were equipped with the skills and training necessary to provide high quality patient care.
  • The emergency department provided an education programme and outreach service to local education establishments on the dangers of knife crime with the aim of reducing this particular type of crime in the local population.
  • The critical care team led by a designated consultant was developing guidance for staff in the application of the Mental Capacity Act 2005 and associated deprivation of liberty safeguards in the critical care setting. It was hope that this guidance once approved would be adopted across both the local and national critical care networks.
  • The electronic whiteboard system used across the trust provided staff with information as to the bed allocated to each patient and to whether patients had particular assessments completed, for example venous thromboembolism (VTE). The board was also used to highlight vulnerable patients. We viewed the whiteboard on ward 3X where staff were piloting an increased functionality such as access to the National Early Warning Score (NEWS), referrals, graphs of patient’s results over time and interaction with medical staff via the white board. We found this to be good practice and innovative.
  • The trust had a comprehensive end of life vision and strategy set out for 2013- 2018. Their vision was to deliver the highest quality healthcare driven by world class research for the health and wellbeing of the population. End of life services had partnered with Marie Curie Palliative Care Institute Liverpool (MCPCIL) to further research and develop end of life services and collaborated with the Cheshire and Merseyside end of life network group to share research findings. This collaborative working helped support the commissioning and provision of excellent and equitable end of life services for the people of Merseyside and the surrounding boroughs.
  • The trust had developed and opened a new Academic Palliative Care Unit (APCU), providing a 12 bedded unit for patients who were at the end of life.
  • The trust had a well-established and well-staffed palliative care directorate that worked closely with other organisations to improve the quality of end of life services in Merseyside.
  • The palliative care service was embedded across the trust and held in high regard by all the wards we visited. Palliative care was integral to the trust and had a well-developed and substantial palliative care directorate that was part of the medicine division.
  • The trust had a robust education and training programme in end of life care and a formal programme of study days which was co-ordinated by the Hospital Specialist Palliative Care (HSPC) team and provided in conjunction with MCPCIL.
  • End of life services had a substantial care of the dying volunteer service to ensure that patients and their families were supported. The volunteer service were winners of the Deborah Hutton award in 2015.
  • Through working in partnership with the MCPCIL they had developed and appointed two discharge co-ordinators and implemented a rapid discharge home to die pathway. This had achieved excellent results in ensuring end of life patients were supported to be discharged to their preferred place of care.
  • Care provided to patients went beyond most people’s expectations. Staff showed care and compassion and went the extra mile to ensure patients at the end of life were well cared for. Care for patients and their families was the responsibility of all staff and not just the HSPC team.
  • The mortuary staff were able to carry out reconstruction and camouflage to deceased patients to ensure that bereaved families were able to view their loved one.

However, there were also areas where the trust must make improvements.

Importantly, the trust must:

  • Ensure that the trust discharges its responsibilities in relation to the duty of candour for all incidents that meet the criteria.
  • Ensure that robust arrangements are in place to govern the fit and proper persons process.

In all areas

  • The trust must ensure that fridges used to store medications in all areas are kept at the required temperatures and checks are completed on these fridges as per the trust’s own policy.

  • Where fridge temperature ranges are recorded outside the recommended minimum or maximum range, steps must be taken to identify if medicines stored in the fridges are fit for use.
  • The trust must ensure that medicines, including controlled drugs and intra-venous (IV) fluids, are securely stored in line with legislation.
  • The trust must ensure that emergency resuscitation equipment is readily available in each area, to provide timely access to emergency resuscitation equipment. At the time of the inspection we found equipment shared between wards at the Royal Liverpool University Hospital which meant there may be a delay in accessing emergency equipment.
  • The trust must ensure that all emergency equipment is checked regularly in line with trust policy and is ready for use in order to be able to respond safely in an emergency situation.
  • The checking of medication, including controlled medication must be carried out consistently as per trust policy.
  • The trust must ensure the expiration date of medicines is monitored. Drugs that are past their expiry date must be disposed of promptly.

In Medical care

  • The service must ensure controlled drugs are stored in line with the legislation on the Acute Medical Unit (AMU) at the Royal Liverpool University Hospital.
  • The service must find an acceptable option to ensure its compliance with Health and safety best practice guidance for the storage of portable oxygen.

In addition, the trust should:

  • Take steps to engage with allied health professionals (AHPs) so they are aligned professionally with an executive lead.
  • Take steps to improve the oversight of actions arising from serious incidents and clinical audits.
  • Take steps to improve the time taken to upload incidents to the national reporting and learning system (NRLS).
  • Take steps to monitor the timeliness in reporting serious incidents and instigating the duty of candour.
  • Review risk registers and the board assurance framework to provide assurance that risks are recorded correctly, being managed appropriately and mitigated in a timely way.
  • Consider how to engage more widely with staff groups that have protected characteristics.
  • Review its Equality Delivery System (EDS2) methodology to ensure it achieves the expected outcomes.

Professor Sir Mike Richards

Chief Inspector of Hospitals


CQC inspections of services

Inspection carried out on 28-29 November and 11 December 2013 and 30 June-1 July 2014

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

The Royal Liverpool and Broadgreen University Hospitals NHS Trust is one of the largest hospital trusts in the north of England serving more than 465,000 people in Liverpool. The trust currently delivers acute services from two sites: Royal Liverpool University Hospital and Broadgreen Hospital. It also includes the Liverpool University Dental Hospital at a third site. There is a new hospital project underway which is due for completion in 2017. As well as providing general services to local communities, the trust provides regional and national specialist services and is considered to be one of the UK's leading cancer centres. The trust is closely linked with the University of Liverpool and John Moores University for teaching and research.

The Royal Liverpool University Hospital is the largest hospital in Merseyside. It has over 40 wards, more than 750 beds (excluding day case and dialysis beds). It has the main accident and emergency department for the city of Liverpool capable of dealing with major trauma and life threatening illness. Broadgreen Hospital is the main location for the trust's elective general, urological and orthopaedic surgery, diagnosis and treatment, along with specialist rehabilitation. It has 3 medical wards, 2 surgical wards, a theatre suite and a Postoperative Extended Care unit (PAECU). 

We inspected this trust as part of our new in-depth hospital inspection programme. It was being tested at 18 NHS trusts across England, chosen to represent the variation in hospital care across England. Before the inspection, our ‘Intelligent Monitoring’ system indicated that the Royal Liverpool and Broadgreen University Hospitals NHS Trust was considered to be a low-risk provider. CQC had inspected across both of the acute sites four times in total since it was registered in April 2010. It had always been assessed as meeting the standards set out in legislation.

Before the visit our analysis of data from our ‘Intelligent Monitoring’ system indicated that the hospital was operating safely and effectively across all key services. The trust’s mortality rates in cardiology, other injuries and conditions due to external causes and miscellaneous were worse or much worse than expected although in infectious diseases they were much better than expected. The trust had been identified as a mortality outlier for patients admitted as an emergency case with an acute myocardial infarction. Investigation by the trust concluded that this was due to miscoding and action plans were put in place which will be monitored by the CQC local compliance team. We also reviewed information that we had asked the trust to provide and received valuable information from local bodies such as the clinical commissioning groups, Healthwatch, Health Education England and the Medical and Nursing Royal Colleges.

We also met with a group of local people representing people who can be more difficult to reach for their views before the inspection. We listened to people’s experiences of the trust and during the inspection we held a public listening event in Liverpool and heard directly from 30 people about their experiences of care. We spoke with more than 100 patients throughout the inspection.

We issued six compliance actions to the trust in February 2014 in respect of following national and local guidance and policy. We re-inspected to monitor compliance with these compliance actions on 30 June and 1 July 2014. We found that the trust was compliant in respect of the issues contained within five of the compliance actions. Where this follow up inspection reviewed issues at the trust this report has been updated to reflect this.

At the inspections in November and December 2013 and January 2014 our team included CQC inspectors and analysts, doctors, nurses, experts by experience and senior NHS managers. The team spent two days visiting the two acute hospitals, conducted a further unannounced visit a week later, and returned to Broadgreen for a follow up visit in January.  Between the hospitals we held focus groups with different staff members from all areas of both hospitals and spoke to 100 members of staff. We looked at patient records of personal care or treatment, observed how staff were providing care, and talked to patients, carers, family members and staff.

Overall we found the trust provided excellent care in some areas including the end of life care service which was of a high standard and provided care seven days a week. In critical care, there was a formal critical network in place with other local trusts which ensured the needs of patients were met effectively. There was also an effective Critical Care Outreach Team (CCOT) and an Acute Response Team who support patients who had received care within the Intensive Care Unit. Medical and surgical care at the Royal Liverpool was being delivered well under difficult staffing circumstances and the staff should be praised for their commitment and hard work to maintain safe practice. The emergency department should also be commended for the hard work they put in to caring for the large numbers of people who attend the department.

The team were impressed with the surgical services provided at Broadgreen, seeing many examples of very good responsive care and received consistently complementary feedback regarding medical and surgical care.  Wards and departments were well staffed and there was evidence of innovative practice within the surgical department and the postoperative extended recovery unit provided good care. 

On both sites we met staff who were hardworking, caring and compassionate and who were proud to work for the trust. We found an open culture where staff could raise their concerns and felt supported in their roles. The trust was clean and there was hand hygiene gel available in all areas.    

However, we also found there were some areas of concern which the trust must address.

Staffing was found to be adequate at the time of the inspection, but this was being supported by overtime, bank and agency work, particularly at the Royal Liverpool. The recruitment of substantive staff was being significantly delayed and this was impacting on staff morale. The excessive workload of junior doctors in vascular and colorectal surgery needs to be addressed to maintain safe and effective care delivery. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.

In critical care the roles of the Acute Response Team and the Coronary Care Outreach Team must be clearly defined to ensure the appropriate specialist skills are employed to deliver care to the vulnerable patients these teams care for. The response to patients whose condition is deteriorating should be improved by the support of training for ward staff in how to respond to the needs of these patients in order to ensure specialist intervention in a timely manner to promote the best outcomes. Training for ward based staff regarding the care of patients with tracheostomy will relieve the pressure on critical care beds once they can be cared for on the wards. The Postoperative critical care unit (POCCU) at the Royal Liverpool must ensure that the staff working there are appropriately trained and registered post-anaesthesia care unit practitioners. In addition, the trust must address the inappropriate use of the theatre recovery area at the Royal Liverpool as overnight accommodation for which it is not designed. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.

In the emergency department, the use of an observation room as overnight accommodation for which it is not designed must also be addressed.  There were also concerns raised regarding the adherence to infection control policies in the emergency department, especially at times of high demand. Some equipment used at these times was not clean and should not have been used. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.

The limited allocated space between beds in the Heart and Emergency Centre is unsafe and must be addressed as it currently poses a risk to effective care if patients need emergency equipment by the bed. At our inspection on 30 June and 1 July 2014 there was no actual change to this environment but the trust had robust plans in place to relocate the service to a more appropriate area. Patient safety had been risk assessed for the interim time.

Medicines were administered and stored safely throughout the hospitals. However, at the Royal Liverpool hospital some patients informed us that they had been without at least one item of medication for more than a day during their stay and staff told us the system for obtaining medication for patients to take home once they had been discharged did not work efficiently, particularly at weekends. We noted that there was not a pharmacy service after 12 mid-day on a Saturday until 9am on Monday. This is currently having a detrimental effect on patients who are not receiving all their medication from admission and delaying discharges which is compounding the pressure for beds when the hospital is constantly functioning at high levels of bed occupancy. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.

There was also no electronic drug dispensing system in use in the emergency department at the Royal Liverpool. The staff told us that the pharmacy was not always open and accessible. Staff told us they did not stock all necessary drugs in A&E so they often ended up running to other wards. The emergency department was not set up for ward type drug rounds when people were accommodated for longer periods than usual meaning that the dispensing of drugs was often not safe, there was an additional drain on staff resources and records were not always kept for auditing purposes. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.

At Broadgreen it appeared that up until recently, transfers to the Royal Liverpool site were not being audited. This meant that staff were not able to tell us exactly how many patients had needed to be transferred between the sites and how often this occurred. Although the postoperative extended care unit and recovery area appeared to have very good consultant support, it was not clear to our inspection team whether this was the same on the general medical and surgical wards. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.

From a trust wide perspective, the excessive delays in the recruitment of substantive staff needs to be resolved to reduce the use of temporary staff therefore providing a consistent staff base on which to deliver best quality care. Improvement is required in the care received by patients not cared for on wards of the relevant speciality (known as outliers), it is essential these patients are monitored and managed robustly to ensure they receive the same level of care as patients cared for on relevant wards. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.

The trust is also required to improve the failings of the risk management processes for the analysis and reporting of potential risks. The evidence has shown that not all significant areas of risk are being escalated appropriately to ensure the senior management and the board are fully informed. If the risks are not fully known they cannot be fully addressed and mitigated. The risk management processes also need to interact with the information from complaints to ensure holistic learning is made and the quality of care assured. We noted that the trust reported a significantly lower number of incidents in comparison to trusts of similar size. This can mean that not all incidents are reported and therefore appropriate lessons are not being learned.

Inspection carried out on 28-29 November and 11 December 20

During a routine inspection

The Royal Liverpool and Broadgreen University Hospitals NHS Trust is one of the largest hospital trusts in the north of England serving more than 465,000 people in Liverpool. The trust currently delivers acute services from two sites: Royal Liverpool University Hospital and Broadgreen Hospital. It also includes the Liverpool University Dental Hospital at a third site. There is a new hospital project underway which is due for completion in 2017. As well as providing general services to local communities, the trust provides regional and national specialist services and is considered to be one of the UK's leading cancer centres. The trust is closely linked with the University of Liverpool and John Moores University for teaching and research.

The Royal Liverpool University Hospital is the largest hospital in Merseyside. It has over 40 wards, more than 750 beds (excluding day case and dialysis beds). It has the main accident and emergency department for the city of Liverpool capable of dealing with major trauma and life threatening illness. Broadgreen Hospital is the main location for the trust's elective general, urological and orthopaedic surgery, diagnosis and treatment, along with specialist rehabilitation. It has 3 medical wards, 2 surgical wards, a theatre suite and a Postoperative Extended Care unit (PAECU). 

We inspected this trust as part of our new in-depth hospital inspection programme. It was being tested at 18 NHS trusts across England, chosen to represent the variation in hospital care across England. Before the inspection, our ‘Intelligent Monitoring’ system indicated that the Royal Liverpool and Broadgreen University Hospitals NHS Trust was considered to be a low-risk provider. CQC had inspected across both of the acute sites four times in total since it was registered in April 2010. It had always been assessed as meeting the standards set out in legislation.

Before the visit our analysis of data from our ‘Intelligent Monitoring’ system indicated that the hospital was operating safely and effectively across all key services. The trust’s mortality rates in cardiology, other injuries and conditions due to external causes and miscellaneous were worse or much worse than expected although in infectious diseases they were much better than expected. The trust had been identified as a mortality outlier for patients admitted as an emergency case with an acute myocardial infarction. Investigation by the trust concluded that this was due to miscoding and action plans were put in place which will be monitored by the CQC local compliance team. We also reviewed information that we had asked the trust to provide and received valuable information from local bodies such as the clinical commissioning groups, Healthwatch, Health Education England and the Medical and Nursing Royal Colleges.

We also met with a group of local people representing people who can be more difficult to reach for their views before the inspection. We listened to people’s experiences of the trust and during the inspection we held a public listening event in Liverpool and heard directly from 30 people about their experiences of care. We spoke with more than 100[GB1]  patients throughout the inspection.

At this inspection our team included CQC inspectors and analysts, doctors, nurses, experts by experience and senior NHS managers. The team spent two days visiting the two acute hospitals, conducted a further unannounced visit a week later, and returned to Broadgreen for a follow up visit in January.  Between the hospitals we held focus groups with different staff members from all areas of both hospitals and spoke to 100 members of staff. We looked at patient records of personal care or treatment, observed how staff were providing care, and talked to patients, carers, family members and staff.

Overall we found the trust provided excellent care in some areas including the end of life care service which was of a high standard and provided care seven days a week. In critical care, there was a formal critical network in place with other local trusts which ensured the needs of patients were met effectively. There was also an effective Critical Care Outreach Team (CCOT) and an Acute Response Team who support patients who had received care within the Intensive Care Unit. Medical and surgical care at the Royal Liverpool was being delivered well under difficult staffing circumstances and the staff should be praised for their commitment and hard work to maintain safe practice. The emergency department should also be commended for the hard work they put in to caring for the large numbers of people who attend the department.

The team were impressed with the surgical services provided at Broadgreen, seeing many examples of very good responsive care and received consistently complementary feedback regarding medical and surgical care.  Wards and departments were well staffed and there was evidence of innovative practice within the surgical department and the postoperative extended recovery unit provided good care. 

On both sites we met staff who were hardworking, caring and compassionate and who were proud to work for the trust. We found an open culture where staff could raise their concerns and felt supported in their roles. The trust was clean and there was hand hygiene gel available in all areas.    

However, we also found there were some areas of concern which the trust must address.

Staffing was found to be adequate at the time of the inspection, but this was being supported by overtime, bank and agency work, particularly at the Royal Liverpool. The recruitment of substantive staff was being significantly delayed and this was impacting on staff morale. The excessive workload of junior doctors in vascular and colorectal surgery needs to be addressed to maintain safe and effective care delivery.

In critical care the roles of the Acute Response Team and the Coronary Care Outreach Team must be clearly defined to ensure the appropriate specialist skills are employed to deliver care to the vulnerable patients these teams care for. The response to patients whose condition is deteriorating should be improved by the support of training for ward staff in how to respond to the needs of these patients in order to ensure specialist intervention in a timely manner to promote the best outcomes. Training for ward based staff regarding the care of patients with tracheostomy will relieve the pressure on critical care beds once they can be cared for on the wards. The Postoperative critical care unit (POCCU) at the Royal Liverpool must ensure that the staff working there are appropriately trained and registered post-anaesthesia care unit practitioners. In addition, the trust must address the inappropriate use of the theatre recovery area at the Royal Liverpool as overnight accommodation for which it is not designed.

In the emergency department, the use of an observation room as overnight accommodation for which it is not designed must also be addressed. The limited allocated space between beds in the Heart and Emergency Centre is unsafe and must be addressed as it currently poses a risk to effective care if patients need emergency equipment by the bed. There were also concerns raised regarding the adherence to infection control policies in the emergency department, especially at times of high demand. Some equipment used at these times was not clean and should not have been used.

Medicines were administered and stored safely throughout the hospitals. However, at the Royal Liverpool hospital some patients informed us that they had been without at least one item of medication for more than a day during their stay and staff told us the system for obtaining medication for patients to take home once they had been discharged did not work efficiently, particularly at weekends. We noted that there was not a pharmacy service after 12 mid-day on a Saturday until 9am on Monday. This is currently having a detrimental effect on patients who are not receiving all their medication from admission and delaying discharges which is compounding the pressure for beds when the hospital is constantly functioning at high levels of bed occupancy.

There was also no electronic drug dispensing system in use in the emergency department at the Royal Liverpool. The staff told us that the pharmacy was not always open and accessible. Staff told us they did not stock all necessary drugs in A&E so they often ended up running to other wards. The emergency department was not set up for ward type drug rounds when people were accommodated for longer periods than usual meaning that the dispensing of drugs was often not safe, there was an additional drain on staff resources and records were not always kept for auditing purposes.

At Broadgreen it appeared that up until recently, transfers to the Royal Liverpool site were not being audited. This meant that staff were not able to tell us exactly how many patients had needed to be transferred between the sites and how often this occurred. Although the postoperative extended care unit and recovery area appeared to have very good consultant support, it was not clear to our inspection team whether this was the same on the general medical and surgical wards. 

From a trust wide perspective, the excessive delays in the recruitment of substantive staff needs to be resolved to reduce the use of temporary staff therefore providing a consistent staff base on which to deliver best quality care. Improvement is required in the care received by patients not cared for on wards of the relevant speciality (known as outliers), it is essential these patients are monitored and managed robustly to ensure they receive the same level of care as patients cared for on relevant wards.

The trust is also required to improve the failings of the risk management processes for the analysis and reporting of potential risks. The evidence has shown that not all significant areas of risk are being escalated appropriately to ensure the senior management and the board are fully informed. If the risks are not fully known they cannot be fully addressed and mitigated. The risk management processes also need to interact with the information from complaints to ensure holistic learning is made and the quality of care assured. We noted that the trust reported a significantly lower number of incidents in comparison to trusts of similar size. This can mean that not all incidents are reported and therefore appropriate lessons are not being learned.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.