The trust manages two major hospitals: Warrington Hospital and Halton General Hospital. The majority of emergency care and complex surgical care is based at Warrington Hospital, while Halton General Hospital provides routine elective surgery and is also home to the Cheshire and Merseyside NHS Treatment Centre building where elective orthopaedic surgery is performed.
Although both hospital sites specialise in particular aspects of care, outpatient clinics for all specialties are provided at both sites so people can access their initial appointments close to home wherever possible.
The Delamere Macmillan cancer support Unit is also based at Halton Hospital.
The trust provides services including genito-urinary medicine services from Bath Street Health and Wellbeing Centre in Warrington.
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 300,000 patients.
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.
We carried out this inspection as part of our comprehensive inspection programme.
We rated Halton Hospital as good, Bath Street Health and Wellbeing Centre as good and Warrington Hospital as requires improvement. We rated the trust overall as requires improvement and good for the caring and effective domains
Our key findings were as follows:
The trust had a vision and strategy with clear aims and objectives. The trust had a framework for the delivery of the trust’s objectives relating to Quality, People and Sustainability. Staff in both hospitals were aware and supportive of the vision and values; they understood the challenges facing the trust and the plans and actions to address them.
There was an established executive team who were well known to staff. Staff were positive about the visibility and accessibility of the senior team especially the Chief Executive and Director of Nursing and Organisational Development.
Staff at Halton hospital confirmed that the senior team had recently visited the site however felt that the executive team could visit more often. Staff at the Bath Street Health and Wellbeing Centre felt remote from the senior team and felt that they could have been better included in the decision making about the services they provided. They were positive about the excellent support they received from the divisional management team and matron.
Staff were committed and passionate about their work. Staff were keen to learn and continuously improve the services they offered to patients
There was good leadership and strengthening governance arrangements across the trust. Recent non-executive appointments were increasing the board’s capacity for strong challenge and scrutiny of performance.
The trust was financially challenged and it was evident that the efficiencies required as a part of their Cost Improvement Programmes (CIP) would not be met in all cases.
Access and flow
The trust had been under pressure from high numbers of emergency admissions through its accident and emergency (A&E) department. Performance against the national A&E target set by the Department of Health operational standard to admit or discharge 95% of patients within four hours of arrival was poor. At the time of the inspection, the emergency department had only met this standard once since April 2014.
The numbers of emergency admissions affected the number of available beds particularly in medicine. Patients were often placed in wards and areas that were not best suited to their needs.
Although the trust had good systems to make sure that patients placed in areas away from the relevant specialist area were seen regularly by an appropriate doctor, patients often experienced a number of moves from ward to ward, sometimes during the night. This was not a positive experience for patients.
Surgical patients were also affected because operations were cancelled if intensive care or inpatient beds were not available. However the trust overall cancellation rate for elective surgery compared well with the England average performance against this standard. The cancellation of surgery was more of an issue at Warrington Hospital as a result of the number of emergency admissions. Cancellation rates at Halton hospital were low.
There were a number of delayed discharges at Warrington hospital. Patients were regularly in hospital longer than they needed to be. The most common reasons for delayed discharges were the completion of assessments, patient choice and waiting for a placement in an appropriate care setting.
The trust was well aware of its challenges in this regard and was working with partners to resolve this issue. However reducing the number of delayed discharges in the hospital remained a managerial challenge. The early supported discharge team for stroke patients worked very well and had resulted in a reduced length of stay and an improved patient experience for this group of patients.
In addition, there were high numbers of delayed transfers of care from the intensive care unit. This had a direct impact on the use of the ‘stabilisation bay’ in theatres. Patients were cared for in the stabilisation bay in excess of the agreed operating policy of 4 hours. Patients could remain in this area for up to 48 hours and the bay was an unsuitable environment for patients to be cared for in the medium term.
The delayed discharges and admissions to the intensive therapy unit were symptomatic of wider patient flow issues within Warrington hospital, including the pressures on A&E.
Discharges at Halton hospital were well managed and timely as this was primarily an elective surgical site without an A&E department and emergency admissions. This was as a result of strategic decisions by the trust to improve the care and experience of elective patients.
Nurse staffing
Nursing staff were caring and compassionate and treated patients and those close to them with dignity and respect. Nurses were committed to giving people a high standard of care and treatment. Nurse staffing levels were calculated using a recognised dependency tool and regularly reviewed. There were minimum staffing levels set for wards and departments. Required and actual staffing numbers were displayed outside each ward and department. Individual ward dashboards showed the breakdown of recruitment and staffing indicators for every ward manager.
The trust had been actively recruiting nursing staff nationally and was planning to recruit nursing staff internationally. Although the numbers of nurses had improved, there were still vacancies in some key areas. In the Neonatal unit, nurse staffing did not yet meet the British Association of Perinatal Medicine (BAPM) Standards. The matron of children’s services had recognised this risk and had developed a plan to achieve staffing compliance by 2016.
Nursing vacancies were covered by bank staff, overtime and agency nurses. Although the wards and departments were suitably staffed at the time of our inspection, the trust acknowledged that the current position was not sustainable in the longer term and was seeking new and innovative ways of attracting and appointing nursing staff. We saw evidence of ongoing recruitment during our inspection and progress was reported at trust board on a monthly basis.
Midwifery staffing
In the maternity service the number of midwives was frequently below the staffing levels set by the trust. In addition the labour ward shift leader was often unable to be supernumerary as they were required to support staffing numbers.
The maternity ward had been closed 16 times in 2014. On seven occasions since then this was as a result of insufficient midwives to provide the service.
The midwife to live birth ratio of 1 to 31 was below with the nationally recommended number of 1 to 28.
Medical staffing
Medical treatment was delivered by skilled and committed medical staff. However, there was 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 services. Vacancies were covered by locum doctors in many instances.
The trust had increased the numbers of doctors employed and continued to recruit medical staff as a priority. However there were times when patients waited for extended periods of time before they could be seen by a doctor.
Safeguarding
Policies and procedures were in place that outlined the trust’s processes for safeguarding adults and children. A safeguarding link nurse and a health visitor for children worked with staff to promote and support good practice and escalate risks of neglect or abuse appropriately.
The electronic patient record system in A&E alerted staff to any safeguarding issues and it was mandatory for staff to complete a safeguarding trigger in the clinical assessment record for all children who attended the department.
Safeguarding policy and procedures were supported by staff training. However, the numbers of staff who had completed safeguarding training varied across the all the trust’s sites and completion rates fell below the trust’s target.
Mortality and morbidity
There were no risks identified with Dr Foster Hospital Standardised Mortality Ratios (HMSR) and the Summary Hospital-level Mortality Indicator (SHMI). There was one outstanding mortality outlier for haematological conditions that was subject to ongoing investigation by the trust.
Mortality and morbidity meetings were held weekly at divisional level across the trust 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.
However, the review process would benefit from more robust oversight and involvement from both the Medical Director and the board. This would support assurance that mortality rates are scrutinised at a very senior level and subsequent learning is applied and monitored for impact.
Incident reporting
The trust had reported 6,937 incidents for the 12 month period and the reporting rate was higher than the national rate for trusts of this size. Although the rate of reporting indicates a positive culture in this regard, there were high numbers of incidents reported as causing low or no harm and the numbers of incidents categorised at moderate harm and above are low. Only 108 were categorised as moderate harm, 15 as severe harm and 7 deaths. This may mean that incidents are downgraded, and thresholds should be revised to promote appropriate and accurate classification.
Incidents were raised via the electronic incident reporting system, by completing paper incident reporting forms or by leaving a message with an automated telephone system that was picked up by the governance team and then entered into the electronic incident reporting system. A trust-wide policy was in place to support this approach. Staff had received training and were confident in the use of the incident report system.
Feedback and learning from reported incidents was shared and applied to improve practice and prevent recurrence. In the medical division, feedback to junior medical staff was felt to be poor. In addition there were examples of staff failing to report incidents due to time pressures or because they sought local solutions. This meant that opportunities for learning could be lost as a result.
Mandatory training
The trust had a comprehensive rolling programme for mandatory staff training. However the numbers of staff who had completed their training varied across the trust. A number of staff groups had not met the trust’s training target at the time of our inspection. Some staff said that they could not go to training sessions because of staffing pressures in their area of work. Managers were aware of the shortfall and were beginning to address the issue; they were confident that targets would be met by the year end. However, it was difficult to see how this could be achieved in the context of existing staffing pressures.
Cleanliness and infection control
There was a high standard of cleanliness throughout the hospital. Staff were aware of current infection prevention and control guidelines and observed good practice. Hygiene audits demonstrated a high level of compliance. There were suitable arrangements for the handling, storage and disposal of clinical waste, including sharps.
Cleaning schedules were in place and displayed throughout the ward areas and departments. There were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment. The trust’s C. diff infection rate had mainly been above the England average since September 2013. However there were no trends identified and the trust remained vigilant in managing infection risks.
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 that identified patients who needed assistance with eating and drinking. Support with eating and drinking was given to patients in a sensitive and discreet way.
In addition, the trust Acute Care Nurse Specialist was winner of the 6C’s ‘Live in Action’ story of the month in October 2014 for her innovative work around supporting hydration in the trust relating to ‘Hello my name is, would you like a drink’
Medicines management
Medicines were provided, stored and administered safely and securely. However the management of medicines stock at Halton Hospital outpatient department required improvement.
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 well-staffed. Patients with dementia were assessed and admitted to the ward based on the severity of their dementia and managed sensitively and compassionately.
- The trust ran a "Hello, my name is...would you like a drink?" campaign to raise awareness within the trust 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.
- The trust performed very strongly in the revalidation of medical staff.
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 all the resident medical officers have the appropriate skills and competencies so there is consistency in the quality of service to patients
- Ensure that nursing and midwifery staffing levels and skill mix are appropriate particularly in medical care services and maternity.
- Take action to improve the levels of mandatory training compliance.
- Take action to 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.
- Improve incident reporting in the outpatient department and medical division.
- Ensure patient records are complete and ready for patient appointments.
- Ensure medicine stocks in the outpatient department are recorded and checked.
The trust should :
- Strengthen board oversight of mortality rates to ensure that learning is applied and monitored.
Professor Sir Mike Richards
Chief Inspector of Hospitals