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Inspection Summary


Overall summary & rating

Good

Updated 20 March 2019

Our rating of services stayed the same. We rated it them as good because:

  • We rated safe, effective, responsive and well led as good at the hospital with caring being rated outstanding.
  • Safe and effective were the same good ratings as at the previous inspection in August 2015.
  • Caring remained outstanding as at the previous inspection.
  • The rating in responsive had improved one rating to good from the previous inspection.
  • The rating for well led went down one rating to good.
Inspection areas

Safe

Good

Updated 20 March 2019

Effective

Good

Updated 20 March 2019

Caring

Outstanding

Updated 20 March 2019

Responsive

Good

Updated 20 March 2019

Well-led

Good

Updated 20 March 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 19 January 2016

We gave the medical care services at Whiston Hospital an overall rating of good. However, we found further improvements were needed in how the service provided care that was effective to patient needs

Patients received compassionate care and their privacy and dignity were maintained. Patients were involved in their care, and were provided with appropriate emotional support.

Incidents were reported by staff through effective systems and lessons were learnt and improvements made from Investigations where findings were fed back to staff. Staff were aware of how to ensure patients’ were safeguarded from abuse and neglect. The wards were visibly clean and staff followed good hygiene practices.

There were effective systems in place to ensure patient safety was monitored and maintained. Staffing levels were overall sufficient to meet the needs of patients. Care was provided in line with national best practice guidelines and medical services participated in the majority of clinical audits. There was a strong focus on discharge planning from the moment of admission and services to support timely discharge were provided seven days a week.

We found that staffs’ understanding and awareness of assessing people’s capacity to make decisions about their care and treatment were variable.

Services took into account the needs of the local people. There were good ambulatory care services and a specialist unit for the frail and elderly.

The hospital had implemented a number of schemes to help meet people’s individual needs, such as the forget-me-not sticker for people living with dementia or a cognitive impairment and the falling leaf symbol to indicate that a patient was at risk of falls. This helped alert staff to people’s needs.

Medical services captured views of people who used the services with changes made following feedback. A survey showed that people would recommend the hospital to friends or a relative.

Staff told us that they felt valued and supported. There was good staff engagement with staff being involved in making improvements for services. All staff were committed to delivering good, compassionate care and were motivated to work at the hospital.

Services for children & young people

Good

Updated 19 January 2016

We gave the Services for children and young people at Whiston Hospital an overall rating of Good; however in some areas we saw elements of outstanding practice.

Treatment and care were delivered in accordance with best practice and recognised national guidelines.

Children, young people and their families were respected and valued as individuals. Feedback from those who used the service was positive. Staff were compassionate, caring and provided effective care to children, young people and their families. Transition and acute community nursing support was comprehensive and made a positive impact for young people transitioning into adult services.

Staff were both creative and flexible to ensure care met the needs of individual children and young people. Feedback from children, young people and parents was exceptionally positive.

Staff were passionate about delivering high quality care and went above and beyond the usual duties to ensure children and young people experienced high quality care

The staff worked well with other teams and worked hard to provide a service to meet the needs of the child or young person who presented to the hospital. Processes were in place to provide an initial or long term service to any child or young person brought to Whiston hospital.

Staff were passionate about working with children and young people and felt valued by senior managers.

There was a good track record of lessons learnt and improvements being made when things went wrong. This was supported by staff working in an open and honest culture with a desire to get things right.

Children, young people and their families were not provided with regular opportunities to comment about the services provided. The trust was in the process of sourcing a system to help them gain an understanding of how children and young people felt about the care provided.

Critical care

Good

Updated 19 January 2016

We gave the critical care services at Whiston Hospital an overall rating of good.

There were sufficient numbers of suitably skilled and experienced nursing and medical staff on duty to care for patients.

Critical care services were being delivered by caring, compassionate and committed staff. We saw patients, their relatives and friends being treated with dignity and respect. The unit provided a critical care outreach service. We found that the critical care service was well led.

Patients and those close to them were positive about their care and treatment.

There were robust systems and processes in place for reporting incidents and there was evidence that learning from incidents was shared.

However, we found that medicines were not always stored securely and regular checking had not picked up on some out of date equipment on the resuscitation and difficult airway management trolleys.

When people required intensive care there were no significant delays in that care being delivered, however, there was often a delay in discharging patients once they had been judged as medically fit for discharge.

The unit continued to collect and submit data for the intensive care national audit and research centre (ICNARC) for validation, so it was able to benchmark its performance against comparable units. This data showed that patient outcomes were within the expected ranges when compared with similar units nationally.

End of life care

Good

Updated 19 January 2016

We gave the end of life care (EOL) services at Whiston Hospital an overall rating of good.

The palliative and end of life patient journey was supported by a strong Nurse led Specialist Palliative Care Team that worked closely with the ward based staff. There had recently been board approval to appoint a specialist consultant with recruitment underway.

We found that staff were committed to providing a good quality service that was delivered with compassion and dignity.

Staff were clear about their commitment to providing care that ensured patients ended their life in a dignified way in their preferred place of care. There were good systems in place for rapid discharge so that patients could return to their preferred place of care at short notice.

Patients were involved in their care, supported to make informed decisions and were provided with appropriate emotional support at a difficult time for patients and those close to them.

The trust had acted on the Department of Health’s National End of Life Strategy recommendations and was introducing the amber care bundle which encouraged talking openly about people's wishes and putting plans in place should the person die.

The service had a work programme in place and wished to develop this into a future strategy for the service. The trust had a board member with a specific lead for EOL care to ensure scrutiny and challenge regarding performance at a senior level.

Staff spoke positively about the support they were given by senior staff and management.

Systems were in place to prevent patients suffering avoidable harm. Incidents were reported by staff appropriately, they were investigated, lessons were learnt and improvements made to the service as a result.

Patients’ medication was well managed with the pharmacy team responding to requests promptly so patients received effective symptom control in a timely way.

Outpatients and diagnostic imaging

Outstanding

Updated 19 January 2016

We gave the outpatients & diagnostic imaging services at Whiston Hospital an overall rating of outstanding.

Incidents were being reported and staff were aware of the reporting system and how to use it. There was evidence of learning from incidents and how this learning was shared across the service and trust wide.

Cleanliness and hygiene was of a high standard throughout the hospital outpatient departments and staff followed good practice guidance in relation to the control and prevention of infection.

The service used electronic medical records that were easily accessible when patients visited the service. Information about patient’s treatment and care needs were obtained from relevant sources before clinic appointments to enable the service to meet the patient’s individual needs. The electronic patient record enabled timely access to information and diagnostic test results during consultation which contributed to patients making fully informed decisions about their care and treatment.

Staff were aware of their role in safeguarding, a reporting process was in place, and staff knew how to escalate issues of abuse and neglect.

Patients attending the outpatient and diagnostic imaging departments received care that was evidence based and followed national guidance. Staff worked together in a multidisciplinary environment to meet patients’ needs.

Staff were competent in their roles and supported by management systems to provide a good quality service to patients.

The service had been proactive in working towards providing seven days services within radiology and pathology services.

Patients were treated in a compassionate, respectful and considerate manner. The majority of patients said the staff had a good attitude, this was also reflected in a patient satisfaction survey.

There were good examples of a clear pathway and assessment planning for patients with additional needs this to ensure they received the appropriate support in a timely manner. This included the use of identifying the need for pre appointment visits to relevant departments to be arranged if required.

Leadership within the outpatient and diagnostic imaging service was very positive, visible and proactive. Managers had a strong focus on the needs of patients and the roles staff needed to play in delivering good care.

All the staff we spoke with were aware of the feedback from the NHS friends and family test. The trust was ranked one of the highest in the country for extremely positive feedback received from patients.

The service had a range of forums to seek patients’ feedback such as the “patient power” group.

The trust ranked in the top 100 places to work in the NHS in an external health journal.

Many of the departments we visited had awards on display and staff and patients were proud to show us what they had achieved. There were many examples of national targets being shortened by internal targets to drive improvements throughout the service.

Surgery

Good

Updated 20 March 2019

Our rating of this service stayed the same. We rated it as good because:

  • The service controlled infection well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • Staff worked together as a team to benefit patients. There were good examples of multidisciplinary working from admission through to discharge and beyond. Different teams worked closely to deliver safe co-ordinated care and treatment.
  • Staff cared for patients with compassion and kindness. Staff ensured that patients and those close to them understood the care they would receive, and helped to minimise their distress.
  • People could access the service when they needed it. Waiting times from treatment were and arrangements to admit, treat and discharge patients were in line with good practice. The service prioritised the care and treatment of patients with the most need.
  • The service cancelled a lower percentage of operations than the England average.
  • The service had managers at all levels with the right skills and abilities to lead the service and provide high-quality sustainable care. The trust scored highly in the 2017 national NHS survey for a number of indicator including; reporting good communication between senior management and staff.
  • There were established governance systems in place to continually monitor and improve the quality of its services.
  • The service engaged well with patients, staff, the public and local & partner organisations to plan and manage services effectively.

However:

  • There was not always a full, clear and comprehensive record kept of all patients care and treatment. Care and treatment was not always delivered as per trust policies.
  • Resuscitation equipment checks and monitoring were not always completed appropriately.
  • During pre-operative assessment patients did not have a pain management plan put in place and the taking of informed consent was inconsistent.
  • Services were not always effective when benchmarked against national averages.

Urgent and emergency services

Requires improvement

Updated 20 March 2019

Our rating of this service went down. We rated it as requires improvement because:

  • The median time from arrival to initial assessment was worse than the overall England median over the 12-month period from February 2017 to January 2018. Data for January 2018 showed that the trusts median time from arrival to initial assessment was 38 minutes compared to the England average of nine minutes. During our inspection however, we had seen that the trust had taken measures to reduce this time and from March 2018 we saw a reduction to less than 15 minutes.
  • Staff and managers were unclear of correct timescales or recording method for example paper or electronic when undertaking risk assessments of patients within the observation areas. We found they were therefore not consistently completed.
  • Medics were trained to safeguarding level two in children’s safeguarding, ten out of 28 senior nurses/coordinators were trained in safeguarding children level three despite providing team leader support to staff in both the adult and paediatric departments 24 hours a day. The department did not meet its target for some nursing staff trained in safeguarding adult level two.
  • Data in March 2018 showed 64% of ambulance journeys had turnaround times over 30 minutes. This was higher than the national average. However, information provided by the trust following our inspection demonstrated the average notification to handover time was 27.28 minutes for March 2018 which equated to 39.4% of patients handing over within 30 minutes. Data submitted to the Royal College of Emergency Medicine showed the department failed in meeting its audit standards. This had been recognised and action plans had been developed to improve patient outcomes.
  • The department failed to meet the Department of Health target to admit, transfer or discharge 95% of patients within four hours of arrival. This was a decline since the previous inspection from 93% to less than 75%. Additional data however, provided by the trust following our inspection showed that in April, May and June 2018 a range of 86.6% to 89.3% was seen which was similar to the England average. The most recent data we had for March 2018 shows the trust’s monthly median total time in A&E for all patients was 184 minutes compared to the England average of 160 minutes.
  • The trust did not identify all risks, for example a ligature risk assessment audit or clear guidance and understanding of clinical risk assessments within the observation area.

However

  • The service had enough staff with the right qualifications, skills and experience to provide the right care and treatment
  • The department controlled infection risk well. Staff kept themselves, equipment and the premises extremely clean, neat and tidy.

  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and stored confidentially.

  • Medications were stored, prescribed, checked and administered in line with best practice guidance.
  • The department had a clear system for reporting incidents which staff understood. Incidents were investigated and a process for sharing lessons learnt to all staff was well embedded.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.

  • The trust’s urgent and emergency care Friends and Family Test performance was higher than the England average from March 2017 to February 2018.
  • Patients were treated with dignity and respect, privacy was maintained and discretion observed.
  • The department was responsive to increasing demand and were working hard to improve access and flow.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action.
  • The trust provided mandatory training in key skills to staff and compliance rates within the emergency department workforce met with the trust’s target of 85%.

Maternity

Good

Updated 20 March 2019

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Since the last inspection, managers investigated incidents and shared lessons learned with the whole team at weekly drop in meetings and using the quality bus. When things went wrong, staff shared information with families and signposted to appropriate support.
  • The service had enough midwifery and nursing staff to care for women in the service. Midwives provided one to one care during labour and delivery supported by the co-ordinator who was supernumerary. A helicopter bleep supported the whole service and could reassign staff if needed.

  • Staff involved women and those close to them in decisions about their care and treatment. Staff worked with different departments in the hospital to support women in different circumstances. Staff told us about making special arrangements for the chosen birth partner to attend labour.
  • The service planned and provided services in a way that met the needs of local people. Since the last inspection there has been the introduction of a midwifery-led unit which offered more choice for low risk women. Women were offered a choice of birth location and supported by named community midwifery teams.
  • The service had managers at all levels with the right skills and abilities to lead the service. Since the last inspection, a new head of midwifery had been recruited as well as other senior midwives with specialist knowledge.
  • Since the last inspection, a new Maternity Strategy has been development and implemented. They also followed the strategy of the regional network of trusts. The trust values were displayed and were embedded with staff we spoke with.

However:

  • Doctors were trained to level two for safeguarding training rather than level three as per intercollegiate guidance.
  • Babies that had been prescribed intravenous antibiotics needed to be escorted to the neonatal unit for the treatment, rather than staying in the maternity unit. This meant there were risks of further infection or possible abduction if a parent was not able to attend.
  • Appraisal rates for midwifery staff was on average 68%, despite delivery suite midwifery compliance of 91%. Three midwives had been trained as professional midwifery advocates to support other staff although this had not been implemented fully.
  • Not all services were available seven days a week, such as antenatal services, routine sonography or the fetal monitoring assessment unit.
  • Women assessed as high risk needed to attend the antenatal clinic at the hospital, rather than their local G.P. This meant women may need to travel a distance to attend.
Other CQC inspections of services

Community & mental health inspection reports for Whiston Hospital can be found at St Helens and Knowsley Teaching Hospitals NHS Trust.