St Helens Hospital is part of St Helens and Knowsley Teaching Hospital NHS Trust and provides a range of hospital services, including general and specialist medicine, general and specialist surgery outpatients and diagnostics.
St Helens Hospital is situated in St Helens Merseyside and serves a population of approximately 350,000 people residing in the surrounding area of Knowsley, Halton, St Helens and the area of South Liverpool.
We carried out this inspection as part of our scheduled program of announced inspections.
We visited the hospital on 19, 20 and 21 August 2015. During this inspection, the team inspected the following core services:
- Medical care services (including older people’s care)
- Surgery
- Outpatients and Diagnostic Services
Our key findings were as follows:
Leadership and Management.
The hospital was well led and well managed. The Executive Team and senior managers were frequent visitors to the site and were well known by staff. Staff felt managers were visible accessible and supportive.
The trust’s vision regarding 5 star patient care was well understood and embedded. Staff were clear about their roles and responsibilities and all disciplines worked well together for the benefit of patients.
There was a positive culture throughout the hospital and staff felt valued and included. They were proud of the hospital and the care and treatment they provided to patients.
Staff and patients were well engaged in service design and development. Staff were supported and encouraged to be innovative to secure improvement and enhance patient experience. In addition there were good opportunities for staff development and a range of staff awards available for both services and individuals that performed well.
Successes were celebrated and shared at a range of staff events including an annual awards celebration that was highly valued by staff.
Access and Flow
- For the period April 2013 to February 2015 the hospital met the 18 week standards for referral to treatment times in all specialties provided at the hospital.
- NHS England data showed the number of elective operations cancelled was better than the England average from July 2014 to September 2014. Trust data between April 2014 and July 2015 showed a low number of operations (87) were cancelled at St Helens Hospital. Reasons for cancellations included the theatre lists overrunning and patients not attending appointments.
- When an operation was cancelled, staff arranged a new date with the patient on the day of the cancellation. NHS England data showed all patients that had their operations cancelled were treated within 28 days since April 2011 which was better than the England average.
- Meetings on bed availability were held four times a day to determine priorities, capacity and demand for all specialities. These were attended by both senior management staff and senior clinical staff.
- Very occasionally there were surgical outliers admitted to Duffy Suite (medical unit). There were recently two patients from Sanderson Suite who had had an operation that day but they only stayed overnight and came with an appropriately trained nurse to look after them.
- As part of managing the admission and discharge processes there was a ‘patient status at a glance’ whiteboard and we observed the daily board round on Duffy Suite. This was a summary discussion of each patient and the status of their admission and any discharge planning and was attended by the multidisciplinary team.
- Patient records showed discharge planning took place at an early stage with multidisciplinary input.
- A policy outlined the selection criteria for inpatient admissions into the Sanderson Suite and a flow diagram procedure was in place for unplanned admissions and for transferring patients to Whiston Hospital if the patient’s condition had deteriorated.
Cleanliness and Infection control
- Patient-led assessments of the care environment (PLACE) showed that the trust has achieved the best PLACE audits nationally for two consecutive years 2014 and 2015.
- The areas we inspected were visibly clean. Cleaning schedules were in place with clearly defined roles and responsibilities for cleaning the environment and decontaminating equipment. Staff were aware of current infection prevention and control guidelines, including the use of ‘I am clean’ stickers to inform colleagues at a glance that equipment or furniture had been cleaned and was ready for use.
- Staff followed correct hand hygiene and 'bare below the elbow' guidance with appropriate protective personal equipment, such as gloves and aprons, whilst delivering care as per National Institute for Health and Care Excellence (NICE) guidance on infection control
- Patients identified with an infection could be isolated in side rooms, if required, with appropriate signage to protect staff and visitors.
- The trust had employed a number of infection control link nurses and a surgical site infection specialist nurse working across both sites. Their role was to provide training and to liaise with staff so patients that acquired infections following surgery could be identified and treated promptly.
- The numbers of MRSA and MSSA infections were below the England average between April 2013 and March 2015. C.diff infections relating to surgery were within expected limits at the hospital between April 2014 and December 2014.
- Infection control training had been completed by 95% of staff, which was above the trust’s target.
Nurse staffing
- Nurse staffing levels were determined using an evidenced based acuity tool.
- Staffing levels were planned to provide an appropriate skill mix to provide care and treatment for patients.
- The expected and actual staffing levels were displayed on a notice board on each unit/ward and these were updated on a daily basis.
- Staffing levels were reviewed every six months using the ‘safer nursing care tool’ (Shelford group, 2013) endorsed by NICE.
- Seniors managers were proactive in managing staff shortages through both escalation and recruitment processes.
Medical staffing
- The wards and theatres had sufficient numbers of medical staff with an appropriate skills mix to ensure that patients received the right level of care.
- There was sufficient on-call consultant cover over a 24 hour period with appropriate medical cover outside of normal working hours and at weekends. The on-call consultants were free from other clinical duties to ensure they were available if needed.
- The hospital employed a resident medical officer (RMO) who was based at the hospital 24 hours per day covering a weekly or fortnightly rota. The RMO was resident on site and available on call outside of normal working hours.
- Existing vacancies and shortfalls were covered by locum, bank or agency staff when required. All agency and locum staff were provided with a local induction to ensure they understood the hospital’s policies and procedures.
- Daily medical handovers took place during shift changes which included discussions about specific patient needs.
Mortality rates
- Mortality and morbidity reviews were held in accordance with trust policy and procedures. and were underpinned by policies and procedures.
- Deaths were reviewed thoroughly and opportunities for learning were shared and disseminated amongst staff teams.
Nutrition and hydration
- There was a wide range of meals available including options for a healthier choice, higher energy, softer (easier to chew), vegetarian, vegan and gluten free. There was a separate menu for modified texture foods which included thick puree, pre-mashed or fork-mash able options for patients with swallowing difficulties.
- There was a patient list with dietary requirements identified, for example identifying if patients were diabetic, dysphasic, on a low residue diet. For patients requiring assistance at meal times a red tray system was in operation so that they could be easily identified. There were also red jugs available, and this system was consistent with the Whiston site so that when patients were transferred the same processes around meal times were in place.
We saw several areas of outstanding practice including:
- The clinical staff in the breast unit had published extensively in their field and had developed innovative approaches to localisation of breast cancer surgery.
- The additional needs pathway and coordinated approach to a patient with additional needs to reduce the need for repeat procedures was seen as outstanding in terms of enhancing the patient’s experience.
- In order to improve the response time and access to timely treatment for a patient, if a critical or abnormal finding on an X-ray was seen designated radiology staff could book another follow up appointment with the appropriate specialist.
However, there were also areas where the trust could make improvements.
Importantly, the trust should
- Consider the review of training of the medicines policy in relation to the administration of regular medication via oral or intravenous routes.
- Consider the review of training around incidents and risks, to include the use of SMART principles when developing and documenting action plans.
- Consider the use of Measles charts or similar tools for mapping the geographical location of falls.
- Ensure all prosthetists receive an appraisal in a timely manner.
- The provider should continue monitoring the ophthalmology services ability to manage the clinic and reduce the waiting time in clinic to improve the patients’ experience.
Professor Sir Mike Richards
Chief Inspector of Hospitals