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Inspection Summary


Overall summary & rating

Good

Updated 23 December 2015

Alder Hey Children’s Hospital is one of two registered locations that forms part of Alder Hey Children’s NHS Foundation Trust. The trust’s other location is the Dewi Jones Unit - an inpatient mental health facility to support young people between the ages of 5 and 14 years.

Alder Hey Children’s Hospital is a specialist acute hospital for children and young people that provides urgent and emergency care, medical care, surgery, critical care, outpatients and diagnostic services, neonatal services, end of life care and transitional services.

Alder Hey Children’s Hospital has 246 beds and provides a wide range of inpatient medical, surgical and specialist services as well as a 24-hour A&E. The hospital is also a designated national centre for head and face surgery, a centre of excellence for heart, cancer, spinal and brain disease and a Major Trauma Centre. It is one of four national Children’s Epilepsy Surgery Service centres. A new Alder Hey Hospital is currently being built adjacent to the existing site and is set to open in 2015.

We previously inspected this hospital in May 2014 and rated it as “Requires Improvement” overall. We judged the hospital to be “Requires Improvement” for safe, responsive, well-led and “Good” for effective and caring. Our main concerns centred on the critical care and outpatients services, but we also had concerns about how the hospital managed the care of young people with complex needs who were due to transition into adult services.

This was a follow up inspection to the comprehensive inspection of May 2014. The inspection was focused and specifically considered the areas that required improvement. The inspection took place on the 15th and 16th June 2015.

We inspected the following core services in full:

  • Critical Care
  • Outpatients and diagnostic imaging services*
  • Transition services

*The last inspection in May 2014 was part of a wave of inspections to test our methodology and at that time, diagnostic imaging was not explicitly included in the outpatients’ methodology. This inspection included diagnostic imaging services, which is part of our updated methodology.

We also looked at the “Safe” domain in the following core services to check whether improvements had been made:

  • Medical care
  • Surgery

It was evident that the trust had made a very positive response to the findings of our last inspection and improvements had been made in all of the areas we identified. The trust had also improved in a number of areas where we indicated it should make improvements with particular reference to the services for young people transitioning in to adult services and in the engagement and inclusion of staff in the change agenda. However, outpatients and diagnostics still required improvement overall.

Despite only inspecting the areas outlined above, we have used the ratings from the last inspection to re-aggregate the overall rating for this hospital. In the lead up to the inspection, we discussed the performance of the trust with commissioners, other regulatory colleagues and stakeholder groups, such as Healthwatch. We did not receive any intelligence to suggest that the areas we rated last time had regressed and this is the basis for re-aggregating the overall rating for Alder Hey Hospital to "Good".

Our key findings were as follows:

  • The trust had significantly improved the levels of nurse staffing. Over 80 additional nurses had been recruited and all of the wards and departments we inspected were adequately staffed to meet the needs of patients.
  • Medical support for the High Dependency Unit (HDU) had significantly improved since our last inspection and it was evident that the trust had taken action to address the lack of medical leadership within the unit.
  • The outpatients department had made considerable progress since our last inspection with regard to the management and availability of medical records. The trust had undertaken a lot of work to achieve their target of ensuring that 95% of records were available for the clinics. Effective systems had been put in place to ensure the availability of records within the department.
  • There has been a significant amount of progress in transitional services since we last inspected and we have been impressed by the trust's response in this area. A clear overarching vision, framework and strategy for transitional care had been developed. The trust had put in place a designated medical and nursing lead for transition who had recently led a review of the arrangements for transitional services and there was evidence of a co-ordinated trust wide approach to transitional services that was monitored at executive level.
  • There was still a shortage of isolation cubicles for children with an infectious disease but the hospital had put plans in place to flex cohort areas and minimise the risk of cross infection. The trust recognises that the issue would not be fully resolved until services moved to the new hospital.
  • The trust had reviewed resuscitation equipment to ensure they met the minimum equipment and drugs required for paediatric cardio-pulmonary resuscitation as outlined in the Resuscitation Council (UK) 2013 guidance. Daily checklists for the equipment were in place; however, the checklist records that we looked at in some areas had not always been completed daily. In radiology we saw that the checklists had not been updated for several months and in some cases a number of years.
  • Patients received care and treatment in a visibly clean environment. Wards and departments were cleaned regularly and cleaning schedules maintained. Staff, in the main, followed good practice guidance in relation to the control and prevention of infection, although hand hygiene practice and the completion of cleaning schedules required improvement in the outpatients and diagnostic departments.
  • The areas we visited were visibly tidy but there were some limitations of the ageing hospital environment which we were told would be addressed as part of the planned move to the new hospital in October 2015.
  • There was good access to interpreter services for children and young people whose first language was not English; however, there was no evidence that the trust provided information leaflets in any other language than in English.
  • Appointment letters and supporting information were only sent out in English and were not available in any other language.
  • Staff within outpatients and diagnostics told us that lessons learnt from the investigation of reported incidents were not always shared to prevent recurrence.
  • Staff in all disciplines remained proud and passionate about their work and there was a strong commitment to delivering and securing the best for children and young people evident throughout the organisation.

We saw that the compassionate care being delivered by staff on the critical care unit was outstanding.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that departmental risk registers are kept up to date and reviewed appropriately.
  • Improve its risk management processes in the outpatient and diagnostic imaging departments and provide appropriate training for those delegated to manage risk.
  • Ensure there is an appropriate process in place for checking and recording pregnancy status in adolescent female patients.
  • Ensure that learning from incidents and complaints is shared with staff to prevent recurrent issues.
  • Ensure that processes are robust and effective in relation to patient emergencies in the radiology department and that first aid and resuscitation equipment is suitably available and checks completed and documented regularly.
  • Ensure that correct hand hygiene measures are in place and that people are aware of and using the correct techniques.

In addition the trust should:

  • Improve staff compliance with mandatory training.
  • Improve staff compliance with safeguarding training.
  • Provide adult safeguarding training for staff across all services.
  • Continue to recruit nursing and medical staff to address shortfalls across the surgical and critical care services.
  • Improve patient access and flow across critical care services.
  • Ensure that people’s medicines are given in the necessary quantities at all times and that the records reflect what has been administered to prevent the risks associated with medicines that are not administered as prescribed.
  • Ensure that outstanding actions on the risk register are reviewed and updated across all departments.
  • Ensure that adequate signage is displayed in relation to entering areas in the radiology department.
  • Seek to fill vacancies on medical wards and reduce the need for locum cover.
  • Continue to recruit nursing and medical staff to address shortfalls across the surgical services.
  • Maintain staffing levels in the Neonatal Unit according to nationally recognised guidance.
  • Implement policies and procedures relating to transition, to ensure there are trust-wide policies and procedures for staff to refer to when dealing with young people that are; or, should be considered for transitional pathways.
  • Ensure that work undertaken in the learning disabilities steering group and the transition steering group are linked so that information is shared and used to benefit both of these vulnerable groups of children and young people.
  • Continue to develop relationships with adult health and social care providers to ensure the safe and effective transition of care for young people.
  • Ensure that appropriate systems are in place for patients or those close to them to raise an alarm if they require assistance whilst in outpatient changing areas.
  • Undertake a review of staffing within each area of the outpatients department to ensure that there is an appropriate system in place to determine staffing requirements.
  • Improve communication with people for whom English is not their first language.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 23 December 2015

Effective

Good

Updated 23 December 2015

Caring

Outstanding

Updated 23 December 2015

Responsive

Good

Updated 23 December 2015

Well-led

Good

Updated 23 December 2015

Checks on specific services

Medical care

Good

Updated 5 October 2017

  • There was a positive culture of incident reporting at ward level and there was evidence of learning and changes in practice following incidents. Staff felt supported by their immediate team colleagues and by senior managers.

  • Staffing levels and skill mix was planned, implemented, and reviewed to keep children and young people safe.

  • Consultants took part in a ‘Consultant of the week’ rota and were present in the hospital during times of peak activity.

  • Age dependent pain assessment tools were in use and analgesia was available to children who required it.

  • The environment was suitable and welcoming to meet the needs of children and young people and their parents and carers. Services were planned and delivered to meet the needs of local area, the North West of England, North Wales and the Isle of Man.

  • We found consent to treatment was clearly recorded in the records we reviewed. We observed staff interacting with patients and their relatives with kindness, dignity and respect. Parents and patients told us they were included in decisions about their care and were kept well informed. The patients and parents we spoke with were extremely positive about the care they received and one parent told us “the staff are like a family, we will miss them when the treatment finishes”.

  • The trust had achieved 100% compliance with all cancer waiting times for the period April 2016 to March 2017 except for one month where they achieved 88%.

  • There was a clear vision which was aligned with the trust vision to provide ‘a healthier future for children and young people’ which was underpinned by a set of values. We observed staff demonstrate the set of values when they were delivering care.

  • There was a process in place to enable the performance, safety, and quality of the service to be reported and reviewed. Risk registers were held at ward and clinical business unit level with a process to escalate risks to keep children and young people free from harm.

Urgent and emergency services (A&E)

Good

Updated 20 August 2014

The service was safe and responsive to children and young people’s needs, however, there were issues regarding nurse staffing levels, especially at night. The trust took immediate action to resolve this concern by providing an additional trained nurse for the full night shift. Some children and young people were concerned that they had to wait for long periods of time on the department and did not always realise that they had been admitted to the observation unit. Staff were caring and approachable, and engaged well with children and young people.

The department’s management team were exploring ways to reduce demand on A&E services and encouraged children and young people to seek alternative avenues of care and treatment to avoid unnecessary admissions to hospital.

Some staff told us that they did not feel appropriately supported by their managers.

Neonatal services

Good

Updated 20 August 2014

Parents we spoke with gave us examples of the good level of care that their babies had received on the NSU. We were told about how supportive staff were, and that parents were informed about the care and treatment their babies received, and were involved in the process.

The NSU had recently introduced a breastfeeding care pathway, Promoting transition to breastfeeding, which was becoming embedded in practice. Mothers spoke positively about the support they received. There was strong local leadership on the unit, with a clear ethos about staff working together.

Transitional services

Good

Updated 23 December 2015

At our previous visit in May 2014 we found that transitional services required improvement. In June 2015, we returned to inspect the whole service. We saw that there had been significant improvements since our last inspection. We found that the trust had a co-ordinated trust wide strategy for planning and delivering transition services which supported young people. There were excellent examples of transition pathways for young people with specific long-term needs. There was a commitment from the trust to further develop existing partnerships with health and social care providers of adult services. Since our last inspection, the trust had appointed a designated transition nurse and named medical consultant. As a result, progress had been made in developing over-arching policies and procedures relating to transition arrangements for young people with complex needs. These were due to be formally rolled out across the trust shortly after our inspection. There was clear leadership, vision and a desire to use research and audit programmes to share good practice and identify gaps in transition and use this to improve outcomes for young people. There was evidence of patient, public and staff involvement in shaping policies and procedures related to transition.

Surgery

Requires improvement

Updated 5 October 2017

  • The hospital did not always ensure that a member of staff who was trained in advanced paediatric life support (APLS) was available on each department at all times. This did not meet the Royal College of Nursing (RCN) minimum staffing requirements

  • We found that compliance with mandatory training across surgical services was mixed. We had particular concerns that compliance with safeguarding level three training for surgical staff overall was only 67% at the time of the inspection.

  • We found that the governance framework for surgical services was relatively new and was still being embedded at the time of inspection.

  • On surgical wards, there was no evidence of formal risk assessments being completed, such as formally assessing the level of risk posed by resuscitation equipment being in different ward areas. We were therefore unsure if all risks had been identified and mitigated appropriately. This was not line with the hospital’s risk management strategy.

Intensive/critical care

Good

Updated 23 December 2015

At our previous visit in May 2014 we found some areas of critical care that required improvement. In June 2015, we returned to inspect the whole service and saw that improvements had been made. The staffing levels and skill mix was sufficient to meet patients’ needs and staff assessed and responded to patient’s risks in a timely manner. Incidents were reported and learning was shared across the departments. The environment was visibly clean, well maintained and in a good state of repair. Staff were aware of infection prevention and control guidelines. Equipment was appropriately serviced and available. Medicines were stored and administered appropriately and patient records were completed appropriately. The majority of staff had completed their mandatory training but there was low compliance in information governance, safeguarding level 3 training and equality and diversity training. Staff worked to policies, procedures and clinical care pathways in line with local and national guidance. Patients were assessed for pain relief and supported in an appropriate manner. Staff had the appropriate skills and knowledge to seek consent from patients and explained how they sought verbal and implied informed consent. Outcomes for children were comparable to similar children’s trusts in terms of mortality, length of stay and unplanned re-admissions. Parents, carers and children were consistently positive about the care and treatment provided. They felt supported, involved and received information in a manner they understood. Staff were compassionate, kind and respectful whilst delivering care. Children were admitted to critical care services in a timely manner; however, there were frequent delays in transfer of care and patients were routinely discharged out of hours. There were plans to address the patient access and flow issues as part of the reconfiguration of services following the planned move to the new hospital site in October 2015. Critical care services were overseen by a clinical director, a lead nurse and a general manager. There was also a designated clinical lead for HDU. Staff felt proud to work at the hospital and morale was high. There were routine clinical business unit risk and governance board meetings and departmental staff meetings where key risks were identified and reviewed. Staff told us they received good management support.

End of life care

Outstanding

Updated 20 August 2014

The specialist palliative care team provided a safe, effective and responsive service. Staff throughout the hospital knew how to make referrals to the team. Children and young people were appropriately referred and assessed by the specialist palliative care team.

The service had developed advanced life care plans in partnership with other service providers in the region for use in hospital and the community. Specialist children’s palliative care nurses supported children and young people in hospital and in the community working in partnership with local community nursing teams. Children, young people and families had access to specialist advice and support 24 hours a day from a nurse-led, on-call team for end of life. Palliative care advice was also available for professionals. A bereavement service supported families’ emotional needs during end of life and afterwards. Counselling support was available through the Alder Centre. Mortuary staff were trained in bereavement counselling.

Outpatients

Requires improvement

Updated 23 December 2015

At our previous visit in May 2014 we found some areas of outpatients that required improvement. In June 2015, we returned to inspect outpatients and diagnostic imaging services and saw that considerable progress had been made with regard to the management and availability of medical records but that the service "requires improvement" overall. Within outpatients and diagnostic imaging services there were areas of governance that required improvement, particularly in relation to the identification and management of risks. There were no regular departmental team meetings taking place at the time of the inspection; however, some departments, such as audiology and the ears, nose and throat department (ENT) held their own multidisciplinary meetings. Lessons learned were not consistently shared with staff. Departmental risk registers were not kept up to date and there was no evidence that they were reviewed on a regular basis. Robust procedures for identifying if young female patients were pregnant prior to undergoing scans within the diagnostic imaging department were described in the trust’s radiation protection policy but they were not always followed. Emergency resuscitation equipment was available in all areas that we inspected. In outpatients, records indicated that the equipment was checked twice daily; however, within radiology, despite staff telling us that checks were completed regularly, we saw that the checklists had not been updated for several months and in some cases a number of years. Mandatory training and safeguarding (level 3) training completion rates for staff within outpatients and diagnostics were low and well below the trust’s target for the majority of the training modules. Completion rates have not improved markedly from the last inspection. Care and treatment was delivered in line with evidence based practice. Policies and procedures followed recognisable and nationally approved guidelines. Patients and those close to them were treated with dignity and respect by caring and compassionate staff. Outpatient clinics were very busy and we observed some carers complaining to members of staff about waiting times. Patient information leaflets, appointment letters and supporting information were not available in any other language except English. There was no process in place for sharing lessons learned from complaints made about the department.

Other CQC inspections of services

Community & mental health inspection reports for Alder Hey Children's Hospital can be found at Alder Hey Children's NHS Foundation Trust.