Arrowe Park Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we rated this key question good. At this assessment, at this assessment, the rating has remained good.

Staff reviewed patients and followed established pathways to ensure they received care and treatment appropriate for their presenting risks. The trust managed mental health risks well. The trust and staff had become much more mental health aware.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them.

Staff reviewed patients and followed established pathways to ensure they received care and treatment appropriate for their presenting risks. This included pathways for emergencies, and major and minor conditions. Although there was a process in place for assessing patient needs, we were uncertain if the patient was cared for in the right place, at the right time, because the areas of the department were unclearly defined, without clear criteria for each area. We were not assured that patients were in the best area (e.g. HD majors vs green/monitored majors with varying staffing ratios).

Falls assessment compliance rates on admission were 87.1% in April 2025 against a review of 1,428 patients, 83.7% in March 2025 against a review of 1,397 patients and 82% in February against a review of 1,210 patients. Results show a slight improvement each month, but figures remain below target.

The trust managed mental health risks well. We were informed by staff that the trust had become much more mental health aware. They worked with the Psychiatric Liaison Team (PLT) to comanage risk, they link in to manage risk and to assess it. There was work underway for MH trained staff to support the ED team assist patients in crisis.

The Psychiatric Liaison team explained that the emergency department had a process for if patients self-present and if patients were brought under S136 of the Mental Health Act (MHA). Staff completed a mental health risk assessment which identified the level of risk. Staff then decided on the management plan. The mental health risk assessment tool prompted staff to consider whether physical health observations were needed. The risk assessment was about the patient but also the department in terms of how staff could manage the risk.

An independent provider supported the department to provide care and observation of patients with mental health risks. This support was often discontinued if the provider staff were required to support elsewhere. If staff needed to leave, then the department’s staff re-assessed the risks and provided additional care support workers or nursing staff to assist. The trust had a standard operating procedure to support the care of patients with mental health needs in the department called Escalation Sequence for Patients with Primary MH Needs.

Mental health assessments completed by the psychiatric liaison service were not accessible to the ED staff, although staff would receive a verbal handover following a mental health assessment by the liaison service. The department regularly cared for patients whose primary needs were mental health. Records and assessments were held by both the ED and psychiatric liaison service.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

We reviewed 26 clinical pathways for ED which appeared appropriate and were up to date. The pathways included but were not limited to, the Major Trauma standard operating procedure (SOP), Paediatric Trauma Guideline: Paediatric Trauma Activation and Transfer to Major Trauma Centre, Patients Presenting with Rape/Sexual Assault to the Emergency Department, and Adult Seizure and Epilepsy Management pathway, as examples.

The ED consultants met weekly as a group. The ED department held monthly clinical governance meetings. We reviewed the meeting minutes from March, April and May 2025 and saw the meetings to be consistently well attended. Discussions included reviews of new or out of date guidance, protocols, policies and audits for approval, patient safety, Covid-19, patient experience including complaints or concerns. The meetings also included general information sharing.

The emergency care department were participating in several projects such as emergency medicine quality improvement projects (QIPs) adolescent mental health, emergency medicine QIPs care of older people (RCEM - Royal College of Emergency Medicine, emergency medicine QIPs mental health self-harm (RCEM), emergency medicine QIPs time critical medications (RCEM), national major trauma registry, door to ECG time to high risk patients in ED (QIP) and audit into benefits of introducing SNAP protocol to paediatric management of paracetamol overdose require treatment. Most were due for completion by the end of 2025 except emergency medicine QIPs - adolescent mental health which was due for completion January 2027.

ED had reviewed and were fully compliant with IPG782 temperature control to improve neurological outcomes after cardiac arrest and subarachnoid haemorrhage caused by a ruptured aneurysm: diagnosis and management. ED were currently reviewing 2 guidelines and undertaking a gap analysis for QS 155 lower back pain and sciatica in over 16s and QS 19 Meningitis (bacterial) and meningococcal disease.

The last ‘Getting It Right First Time’ (GIRFT) visit for ED was 2019 and GIRFT visits were no longer in place. However, the trust was fully engaged with the GIRFT programme and was part of the Further Faster 20 cohorts focussing on ED. This focused on improving category 2 ambulance response times, enhancing 4-hour emergency department performance, reducing 12-hour ED waits and shortening length of stay to improve patient flow.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

The trust advised that the handover process was comprised of three group meetings, held at different times throughout the day. Nursing handovers were held within specific areas, supporting clinical discussions. Meetings were held at the beginning of each shift or when there were any shift changes. Mental health multi-disciplinary team (MDT) handovers included the emergency physician in charge (EPIC), shift leader (nurse), mental health team - attendance at 08:30am meeting, with escalation thereafter. Leaders advised that each handover was fully documented and held consistently throughout the day at 08:30am, 11:30am, 14:30 and 17:30hrs. EPIC medical handover included all doctors on duty, senior nurses for older people (SNOPs), advanced nurse practitioners (ANPs) and therapists. These meetings were held at: 08:00 and 17:00hrs utilising a clinical risk-based approach.

We observed ED handovers for medical and nursing staff. Whilst we observed a positive culture between colleagues, we did not see a robust process which ensured the team were effectively briefed and coordinated to provide effective care. There was limited feedback from the previous shift including information to support the safe management of risk across the full department. The handovers focussed on the transfer of care within individual areas without ensuring a whole departmental awareness within the team. The handovers were not formally recorded and there was no formal handover template. In ED, medical handovers did not consistently evidence an MDT approach. There were multiple brief team handovers between clinicians throughout the day. Medical handovers were limited to a small minority of patients within the department. Handovers did not always have the nurse in charge, frailty team, occupational therapist, or physiotherapist in attendance.

The trust responded to the concerns and stated that ‘within UEC that there was a clear framework for the effective management of handovers to ensure communication flows were optimised across the multi-disciplinary team to assure safety. These mechanisms facilitated a holistic view of risk across the department. This supported escalation as required, ensuring implementation of responsive action and mitigations with senior clinical oversight. This process was documented within the shift leader’s log.’

Nonetheless, the trust conducted a rapid evaluation of the current handover process, to identify areas of further strengthening. They reviewed and updated the EPIC guidance to include handover and safety huddle governance, mechanisms to document all handovers, and safety huddles were agreed. In addition, a trust-wide safety huddle SOP utilising the principles of the patient safety essentials toolkit was agreed and was to include safety and quality concerns and successes from the previous shift, reflecting the Patient Safety Essential Toolkit.

The trust advised that the nursing & medical handovers were paperless. Nursing staff attended the safety huddle upon commencement of the shift, would be made aware of any issues / plans for the day or any learning from recent incidents / complaints and be assigned to an area within the ED. Following this, the nurse would then accept a verbal handover for each patient in their care. Nurses would then access the patients’ health record to ensure they were fully sighted on all aspects of the patient’s care and treatment plan. Any handwritten notes made during the shift would be disposed of via the confidential waste at the end of their shift. The Shift Lead would huddle with the emergency physician in charge (EPIC) several times throughout the shift when areas of concern would be escalated.

During the assessment we observed inconsistencies in the oversight of patients within the emergency department and in transfer to specialities. In the Clinical Decision Unit (CDU) one patient was left 19 hours before medical review due to an administrative error which meant the patient was left under the ED consultant name overnight and not transferred. A computer based platform gave oversight to the acute medical and had been in use within WUTH for over 7 years. All patients that had been referred and / or admitted to medicine were recorded. Records included name, reference number, location, NEWS score, time waiting, responsible consultant, and triage speciality. The system also tracked whether the patient had received a senior and or consultant review, which enabled tracking of all medical patients in ED and new admissions in the UMAC.

We were advised that a number of revisions took place (December 2024) to the functionality of the digital record at the request of the acute medicine team. Several redundant columns were removed, and further changes were made to prevent patients in ED waiting over 24 hours, from potentially not being immediately visible. A further piece of quality improvement work was underway which had been in process for at least 12-18 months but was not in place at the time of the assessment.

The trust advised that a SOP for the ‘Transfer of Adult Patients from ED to other Specialties and Care of Patients Who Remain in ED’ had been agreed and shared with all clinicians working within ED. The SOP was created following the onsite assessment, and the purpose was to ensure a consistent approach to the transfer of care from the ED clinical team to a specialist team on-call. Once seen by speciality and a decision to admit has been made for a patient, that patient would now be under the care of that speciality. The SOP was to be used alongside the existing internal Professional Standards for Effective Emergency Care (2022) and the trust Escalation Policy (2025).

We scored the service as 2. The evidence showed some shortfalls. The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice, and control. The service did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

We did not see evidence or gain assurance that people were supported to manage their health or wellbeing. We observed people deconditioning while waiting on a corridor trolley or waiting room chairs for excessive periods of time, for example, due to a reported 50hr wait for a medical bed.

We scored the service as 2. The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The trust monitored NEWS2 scoring via a report on the trust portal that was real time reporting by area. A monthly report was sent to all divisions and was presented at divisional performance reviews around NEWS 2 compliance. A focus on NEWS2 completion was one of the priorities within the deteriorating patient improvement programme. The trust did not audit escalation for PEWS or NEWS. The average NEWS completion compliance (including CDU) between December 2024 and May 2025 was 83.37%. The worst month was December 2024 at 80.13% and the best month was April 2025 at 85.13%.

The trust did not have a process to monitor sepsis performance at the time of our assessment. The trust participated in an external audit programme for Sepsis until March 2025 and trust wide data was available until July 2024. As a result of trust wide data the trust completed a focused internal audit of 50 sepsis patients in July 2024 which showed low compliance in multiple areas in line with NICE guidelines. The trust took the decision to leave the external audit programme as the data from this was often out of date and did not support rapid improvement. The trust were repeating the internal sepsis audit to measure improvement in the areas highlighted. The results of this current audit will not be available until August 2025.

The last available figures were from July 2024 and showed poor compliance with clinical focus measures within 1 hour. Figures showed 38% compliance with commencing the care pathway, blood culture collection compliance 40%, IV fluids commencement 54%, Antibiotics 62%, serum lactates 66%, and senior review compliance at 66%. This was not in line with Suspected Sepsis: Recognition, Diagnosis and Early Management NICE guideline Reference number: NG51.

However, NEWS2 compliance was good at 94%. We were not assured staff were always following plans and pathways in relation to sepsis and had not received up to date information to verify improvement. Sepsis and deteriorating patient training figures were below trust KPI of 90% and were at 84.9% at the time of the assessment.

We were advised that sepsis and blood culture training had taken place over the last year and that the trust was building a new electronic sepsis pathway that would be more accessible in aiding decision making, enabling real time internal data to be visible. The aim was to implement this system during the current financial year. However, it was not in place at the time of the assessment.

Sepsis was included within the Deteriorating Patient policy and there was a Sepsis and Deteriorating Patient section on the trust staff intranet with information regarding sepsis and its management. However, the latest iteration of the NEWS policy was due for approval at the Clinical Advisory Group in June 2025. We were advised the policy had been updated to include new information regarding Martha’s rule, and the out of hours escalation posters which included changes within surgery.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

The trust had Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) policies in place.

DoLS applications were made to the trust safeguarding team via the trust incident reporting system. DoLS documentation and flags were placed on the patient’s electronic medical record, the flags for DoLS appeared as a safeguarding flag visible in a blue banner bar to notify staff that they were required to view the record to view the details further.

Staff accessed the trust templates to record Mental Capacity Act assessments and Records of Actions to make a best interest decision through the patient’s electronic records.

Referral forms for Independent Mental Capacity Advocate (IMCAs) were located through the patient’s electronic records and guidance was located within the MCA policy. Referrals for IMCA were sent electronically to both local Duty Advocacy and the Safeguarding Team generic inbox.

Compliance audits of Deprivation of Liberty Safeguards and Mental Capacity Act Key performance indicators were outlined within both policies and were monitored through the safeguarding assurance group (SAG) on a quarterly basis. The Mental Capacity Act, Best Interests and DoLS application / restrictions were audited on a daily basis as referral were received. The MCA was also included within the benchmarking audits including Harms Audit, Catheter Insertion, Nutrition and Hydration and Safeguarding Audit.