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Alder Hey Children's Hospital Good


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.

Inspection carried out on 09 February 2021

During a routine inspection

We carried out this announced inspection of the Rainbow Centre children’s sexual assault service over two days on 9 and 10 February 2021 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. Two inspectors supported by a specialist professional advisor, carried out the inspection. To reduce risks presented by Covid-19, we used a combination of remote and face to face interviews.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.


The Rainbow Centre children’s sexual assault referral centre (SARC) is provided by Alder Hey Children’s NHS Foundation Trust. The Rainbow Centre provides co-ordination for all safeguarding activity across the trust. The children’s SARC is part of the trust’s Rainbow Centre safeguarding hub. Access to the Rainbow Centre is via a discreet entrance on the ground floor next to the Emergency Department.

NHS England and Improvement (NHSE/I) commission the children’s SARC with a financial contribution from Merseyside Police. NHSE/I are the main commissioners who manage the contract although the police commissioners are part of contract monitoring discussions. The Rainbow Centre Children’s SARC sees children and young people up to the age of 16 years. In addition, they see young people between 16 to 18 years if they have additional needs that would make Rainbow SARC the best place for them to be seen. The SARC sees patients who have experienced or are suspected of having experienced recent sexual abuse (up to 21 days previously) and non-recent sexual abuse (occurring outside that timeframe). An assessment is made for each referral. The service provides forensic medical examinations and related health services to children and young people from Liverpool, Sefton, Knowsley, St. Helens and Wirral who have been sexually abused. Alder Hey is also a tertiary centre therefore they sometimes see children from the wider North West region. For example, patients who have accessed another service in the hospital and then need access to a SARC. The service is also commissioned to provide a psychology service to children and young people who access the SARC. The psychology service was not in the scope of this inspection.

The SARC service is available 24 hours each day although children and young people are rarely seen out of standard working hours. Access to the SARC is by police or social worker referral only. The forensic examinations are carried out by two doctors. The Forensic Medical Examiner (FME) and a paediatric doctor. The FMEs are provided by St Mary’s SARC, Manchester University Foundation Trust (MUFT) from the St Mary’s Merseyside adult SARC rota. The paediatric doctors are provided by Alder Hey Children’s NHS Foundation Trust. There is a safeguarding consultant paediatrician on call to support the paediatric doctors until midnight. There are two specialist safeguarding nurses provided by Alder Hey who have recently completed forensic nurse specialist training. They offer patients sexual health follow up at Alder Hey two days-a-week. Health care assistants provided by Alder Hey deliver the role of crisis support workers. There are two administrators at the Rainbow Centre who support the work of the SARC.

The service referred patients for follow up to local independent sexual violence advocacy services (ISVA).

Alder Hey Children’s NHS Foundation Trust is responsible for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

The lead clinician has completed the Faculty of Forensic and Legal Medicine examinations and is on the General Medical Councils (GMC) specialist register for Clinical Forensic and Legal Medicine. The FME’s covering the rota for the SARC have a range of specialist qualifications including Forensic and Medical Examinations in Rape and Sexual Assault (FMERSA) training and some had obtained or are working towards FFLM membership.

During the inspection we spoke with nine staff. No patients accessed the SARC during the time that we were on site.

We looked at policies and procedures and other records about how the service is managed.

Throughout this report we have used the term ‘patients’ to describe children and young people who use the service to reflect our inspection of the clinical aspects of the SARC.

Our key findings were:

  • The staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • The staff worked collaboratively to provide a child focused, holistic service and to reduce risks to children and young people.
  • The service had systems that helped them manage risk.
  • There were processes for monitoring the standard and quality of care.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The service had thorough staff recruitment procedures.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • The appointment/referral system met patients’ needs.
  • The service had effective leadership and a culture of continuous improvement.
  • Staff felt involved and supported and worked well as a team.
  • The service asked patients for feedback about the services they provided.
  • The service had suitable information governance arrangements.
  • The service appeared clean and well maintained.
  • The service had infection control procedures that staff followed and which reflected published guidance.

There were areas where the provider could make improvements. They should:

  • Identify effective processes to regularly review the partnership agreement for MUFT staff.
  • Complete checks to ensure that processes for securing Disclosure and Barring Service (DBS) renewals are effective
  • Develop an effective way to record FME’s local induction.
  • Advise patients of the gender of the examining staff and offer a choice of gender where possible.
  • Provide visible and accessible information to patients to help them to feedback and or make complaints about the service.
  • Obtain a fridge thermometer that alerts staff if the temperature in the fridge has gone above or below the recommended levels between checks.

Inspection carried out on 14 Jan to 13 Feb 2020

During a routine inspection

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

  • We rated effective, responsive and well-led as good. We rated caring as outstanding. We rated safe as requires improvement.
  • We rated the five hospital core services we inspected overall as good at this inspection. We improved the overall rating of outpatients and surgery at this inspection.
  • Patients had good outcomes because they received effective care and treatment that met their needs.
  • Patients were supported, treated with dignity and respect, and were involved as partners in their care.
  • Across most services, patients’ needs were met through the way services were organised and delivered.
  • The leadership, governance and culture promoted the delivery of high-quality person-centred care.


  • Although we found the hospital’s services largely performed well, it did not meet some legal requirements relating to the safe domain, meaning we could not give it a rating higher than requires improvement in this domain. We found that across most areas, people were protected from avoidable harm and abuse.

Inspection carried out on 6 to 28 Feb 2018

During a routine inspection

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

We did not aggregate the diagnostic services at this inspection as it was an additional service which was inspected with outpatients before.

A summary of services at this hospital appears in the overall summary above.

Inspection carried out on 19, 20 April 2017 and 5 May 2017

During an inspection looking at part of the service

Alder Hey Children’s NHS Foundation Hospital is one of the busiest children’s hospital in Europe and provides care for more than 270,000 children, young people and their families every year. The trust provides a range of services and leads on research into children’s medicine. The trust also provides child and adolescent mental health inpatient and community services.

Before visiting the trust, we reviewed a range of information we held and asked other organisations to share what they knew about the trust

We carried out this responsive inspection on 19 and 20 April 2017 and 5 May 2017 following increasing concerns we had about the services. We inspected surgical and medical care services.

We did not inspect urgent and emergency services, critical care, neonatal services, end of life care, outpatient and diagnostic imaging or transitional services.

We last inspected the services in September 2015 and we rated the hospital as ‘good’ overall.Surgical and medical care services were judged to be good overall however, there were areas for improvement.

At this inspection we judged that surgical services requires improvement and medical care services as good. These ratings did not affect the Alder Hey Children’s NHS Foundation Trust overall rating.

Our key findings were as follows:

Medical care services

  • Children, young people, and those close to them were treated with respect, dignity, and compassion.

  • Staffing levels at the time of inspection met standards set out by Royal College of Nursing.Staff told us the trust found it challenging to recruit to junior doctor vacancies but had made an investment to train advanced nurse practitioners to partially address the shortfall.

  • Medicines were safely stored in areas that were accessible to staff only, and each area had a dedicated pharmacist based on the wards.

  • Staff were aware of their safeguarding roles and responsibilities and knew how to raise matters of concern appropriately.

  • The environment was suitable and welcoming to meet the needs of children and young people and their parents and carers. The individual needs of patients were met and included children and young people with learning and physical complex needs.

  • The ward areas we visited were visibly clean. We saw that staff followed good practice in relation to the control and prevention of infection.

  • Assessment of nutrition and hydration formed part of the nursing record and was completed in all of the records we reviewed at the time of our inspection.We observed fluid balance charts recorded on the electronic record and children and young people had their weight recorded to inform dietary requirements.

  • A range of menus were available and included age appropriate foods. Children and young people could also request additional options.

  • Staff told us they felt supported by their immediate team colleagues and by senior managers and the working relationships between nurses and medical staff, and allied health professionals worked well.

  • There were communication systems in place to keep staff informed which included newsletters, emails, and safety huddles. Staff confirmed they received updates and information via these systems.


  • We were not assured that children and young people were receiving treatment for sepsis that reflected national guidance. We found delays in the review process but the trust had commenced training to improve the management and identification of sepsis.

  • The compliance rate for safeguarding training level three for children was on average 80%, which was below the trust’s target of 90%. This was highlighted as an area of concern following the last inspection, however there had been an increase in compliance since the last inspection.

  • There were low levels of compliance with mandatory training for medical staff within the medicine clinical business unit. Only 55.2% of medical staff were up to date at the time of the inspection which was significantly worse than the trust’s target of 90%.

  • Medical records were not securely stored on each ward we visited so confidentiality was at risk. Patient privacy and dignity was not fully maintained on wards we visited due to the display screen which was visible to people entering the wards.

Surgical services

  • 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.The trust had acknowledged this shortfall in a recent review but at the time of the inspection no formal plans had been made to implement the improvements.

  • 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. This had only slightly improved since the last inspection despite actions being put in place to increase compliance. At the last overall compliance with safeguarding level three training was 57%

  • On surgical wards there was a risk of abduction or that children were able to leave the ward unnoticed. This was because all doors could be opened from the inside and exit buttons were not out of reach from children. This risk was highlighted when the hospital was built in 2015 but it was unclear if this had been formally risk assessed or what actions had been taken to rectify this and it still remained a risk at this inspection.

  • We sampled various departmental and clinical business unit risk registers and found that in a number of cases there was limited or no evidence that the risks had been reviewed fully or details about how the level of risk had been mitigated appropriately.

  • Resuscitation equipment was available on every department. However, on the surgical wards the equipment was kept in different boxes and in different locations posing an additional risk.

  • Complaince with infection control standards on the wards was consistently low ranging between 54% and 72%.

  • There were currently no audits being undertaken measuring if patients were compliant with the fasting guidance before undergoing a surgical procedure.


  • There were sufficient numbers of staff on the days of our visit to safely care for patients. This was both on the wards and in theatre. In theatre staffing was in line with national guidance.set by the Association for Perioperative Practice (AfPP).

  • We found a strong, person-centred culture. Holistic care was provided by kind and caring staff who made every effort to provide support to patients and their parents.

  • Patients and their parents were actively involved with decisions about care and treatment and their views and wishes were respected and valued.

  • The surgical clinical business unit (CBU) held monthly morbidity and mortality meetings. We saw evidence of actions and learning that had been implemented following these meetings.

  • We observed both the theatre and ward areas to be visibly clean. In theatre, there was an identified lead for infection prevention and control (IPC) and they undertook regular audits which showed that overall compliance had improved to 99%.

  • There were procedures in place to provide fasting guidance to patients and relatives at the pre-operative assessment stage.

  • Nutrition and hydration assessments were undertaken as part of the pre-operative assessment and for admissions to the inpatient wards. There was access to a dietitian during normal working hours between Monday and Friday if needed.

  • A range of menus were available to all patients. We spoke to several patients and relatives, who told us that the food was excellent and that there was a lot of choice. Relatives were also able to order food.

We saw several areas of outstanding practice including:

  • Each ward had their own dedicated pharmacist and medication was accessed by fingerprint technology this ensured that medication was secured and stock levels were adequately controlled.

  • There was a chef allocated to each ward and all food was prepared on the ward.

  • A hybrid theatre had recently been opened and a small number of operations had been undertaken using this facility. This was the first paediatric hybrid theatre to be opened in Europe.

  • The hospital innovation team had worked collaboratively with a local university to develop ‘virtual surgery’ and to use high definition 3D printing so that organs can be viewed in much more detail. This allowed staff to ‘virtually walk around’ organs.

  • The Trust had pioneered a headspace project which had created the world’s first normal equivalent model of the human head. This enables comparison of pre-operative and post-operative 3D images of craniosynostosis patients.

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

Importantly, the trust must:

  • The trust must take action to ensure all staff who are involved with assessing, planning, and evaluating care for children and young people are trained to safeguarding level three in line with the safeguarding children and young people: roles and competencies for health care staff Intercollegiate Document (2014).

  • The trust must take action to ensure all children and young people receive treatment in relation to sepsiswithin appropriate timeframes and have a process tomonitor adherence to policy for patient’s treated for sepsis.

  • The trust must ensure that there is a member of staff trained in advanced paediatric life support available in every department at all times as outlined in the Royal College of Nursing guidelines.

  • The trust must ensure that compliance with mandatory training is improved, particularly for medical staff.

  • The trust must ensure that formal risk assessments are undertaken in all departments and all identified risks are captured on the risk register where needed.

In addition the trust should:

  • Review the systems in place to enable staff to be clear about their roles and responsibilities during an emergency resuscitation scenario.

  • The trust should ensure that all resuscitation equipment on inpatient wards is checked fully in line with the hospital resuscitation policy.

  • Review the systems in place to mitigate the risk of children and young people absconding or being abducted from the ward areas.

  • Expedite plans and actions to enable all staff to improve compliance with mandatory training to the trust’s target of at least 90%.

  • Have safe storage facilities in place for medical records on all wards to protect children and young people’s confidentiality.

  • Have disease specific pathways in place that are based on up to date evidenced based practice and a system for assurance during the period of transition from paper to electronic pathways.

  • Improve staff appraisal rates to reach the at least the trust’s target of 90%

  • Consider training on the Mental Capacity Act for clinical staff being part of the mandatory training.

  • Ensure visual display screens on the wall behind the desk to the entrance of wards do not compromise patient confidentiality.

  • Identify review dates on all risk registers and review monitor that actions identified to mitigate risk are in place in medical services and surgical services

  • Consider implementing a schedule for replacing curtains in the ward areas.

  • The management team should consider ways in which to improve monitoring of surgical site infections for patients who have undergone non-specialist surgery.

  • The management team should make sure that discarded controlled drugs across all departments are recorded appropriately.

  • The management team should consider ways in which to improve the meditech system so that it accurately reflects the time that medicines had been administered, reducing the potential risk of a medication overdose.

  • The hospital should find ways in which to make sure that there is always a supernumerary co-ordinator available in all areas, at all times to support staff.

  • The management team should ensure that all staff receive a full annual appraisal in line with the trust supervision policy.

  • The hospital should consider ways in which to reduce the number of cancelled surgical procedures, and when this does happen to facilitate a further appointment within 28 days of the cancellation.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection carried out on 15 - 16 June 2015

During an inspection looking at part of the service

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 carried out on 21-22 May 2014

During a routine inspection

Alder Hey Children’s Hospital is one of two locations that formed part of Alder Hey Children’s NHS Foundation Trust. The trust’s other location was the Dewi Jones Unit, which was an inpatient mental health facility to support young people between the ages of 5 and 14 years. Until recently, the trust had two other locations based at Broadgreen Hospital and Liverpool Women's Hospital; these locations have now been de-registered. Alder Hey Children’s Hospital was an acute hospital and provided accident and emergency (A&E), medical care, surgery, critical care, neonatal services, adolescent and transitional services, palliative and end of life care and outpatients services.

Alder Hey Children’s Hospital had 246 beds and provided a wide range of inpatient medical, surgical and specialist services as well as 24-hour A&E and outpatient services. The hospital was 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.

The Care Quality Commission (CQC) carried out this comprehensive inspection because the Alder Hey Children’s NHS Foundation Trust had been flagged as a potential risk on CQC’s intelligent monitoring system (which looks at a wide range of data, including patient and staff surveys, hospital performance information, and the views of the public and local partner organisations). The inspection took place between 21 and 22 May 2014 and an unannounced visit took place between 6am and 11am on Sunday 1 June 2014.

Overall, this hospital requires improvement. We rated it ‘good’ for caring for children and young people and providing effective care, but improvements are needed in providing safe and responsive care and being well-led.

Our key findings were as follows:

  • Staff were caring and compassionate and treated children and young people with dignity and respect.
  • The hospital was clean and well-maintained. Infection control rates in the hospital were managed effectively. However, there were insufficient cubicles available within the hospital wards with which to isolate children and young people who may represent an infection risk to others...
  • The trust had a well-established mortality review process that was comprehensive and robust.
  • There were systems and processes for reporting and escalating incidents and concerns; these were well understood by staff. However, staff did not always use the system to report all incidents.
  • Further work was needed to improve the quality of food and ensure children and young people had access to food and drink, particularly in the A&E department.
  • There were concerns about nurse staffing levels across the A&E department, medical wards and surgical wards. Medical cover needed to improve in critical care services.
  • Some children and young people were concerned that they had to wait for a long time in the department and did not always realise that they had been placed on the observation unit.
  • In the medical department, care was planned and delivered in a way that took children and young people’s wishes into account. National guidelines were used to treat children and young people. Care pathways were reflected national guidelines. Standards were monitored and outcomes were good when compared with other children’s hospitals. Access to advice and information was good for children and young people, their families and carers, both during the hospital stay and after discharge.
  • In the surgical department, staff provided safe services to children and young people because they followed best practice guidance in care and treatment. Care was person-centred. Surgical staff were well-trained and the recovery rate for children and young people was favourable when compared with similar hospitals.
  • A consultant surgeon was available either in the hospital or on call for 24 hours each day and middle grade surgeons were on site 24 hours a day, seven days a week.
  • In the paediatric intensive care unit (PICU) there was evidence of strong medical and nursing leadership.
  • The neonatal surgical unit (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.
  • In adolescent and transitional services, we found examples of excellent pathways for young people with specific long-term health needs who were transitioning to adult services. We found that there was no overall responsibility or leadership for transitional services in the trust.
  • 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. A bereavement service supported families’ emotional needs at the end of life and afterwards. Counselling support was available through the Alder Centre.
  • In the outpatient’s service, children, young people and staff told us that one of the biggest challenges was late running clinics and missing case records. Although there had been recent improvements, many staff, particularly in the general outpatient area, said they had not been listened to by management on key service changes and that outpatient services had not been a priority for the trust.
  • Some staff told us they had been actively engaged and communicated with about the move to the new hospital site, while other staff told us they had not.

We saw several areas of outstanding practice including:

  • Alder Hey Children’s Hospital has a gait laboratory to assess children with neuromuscular disorders, such as cerebral palsy, which is not available elsewhere in North West England. The service therefore receives referrals from all over the North West.
  • Trust physiotherapists have linked with community physiotherapists to provide appropriate postoperative care and a trust audit demonstrated that this has translated into improved outcomes for the children and young people.
  • When babies were admitted to the NSU, parents were taught correct hand-washing techniques. The unit was developing infection control safety cards for parents.
  • The paediatric oncology unit has a ward-based chef and kitchen providing freshly prepared food for children and young people between 11am and 7pm.

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

Importantly, the trust must:

  • Continue to address staffing shortfalls. Nurse staffing levels must also be appropriate in all areas, without substantive staff feeling obligated to work excessive hours or additional shifts.
  • Provide a longer-term solution for the medical leadership on the HDU.
  • Ensure that children and young people who require one-to-one support in the isolation pods on the HDU receive it.
  • Take action to ensure there are sufficient levels of nursing staff across the HDU.
  • Continue to take action to ensure that clinical records are available in the outpatients department.
  • Take action to ensure that nurses are following the trust’s policy regarding the safe administration of medicines.
  • Review the resuscitation equipment on each surgical ward to ensure that this meets the minimum equipment and drugs required for paediatric cardio-pulmonary resuscitation as outlined in the Resuscitation Council (UK) 2013 guidance.
  • Address the shortfalls in governance and risk management systems.
  • Improve the timely completion of investigation of incidents and Never Events (serious harm that is largely preventable) so that learning can be systematically applied to avoid recurrence.

In addition the trust should:

  • Review its pharmacy arrangements to improve support to wards out of hours and at weekends.
  • Ensure that the A&E department clarifies its use of the observation ward as a CDU and make it clear to children and young people and their parents when they have been transferred to the CDU rather than being in A&E.
  • Ensure that the A&E department reviews its arrangements for providing food and drinks in the waiting areas, and make it clear that hot and cold drinks and food are available on request.
  • Ensure that children, young people and their parents using A&E services are aware of the trust’s complaints procedure and are supported in using it where necessary.
  • Review the provision of isolation cubicles within the hospital to isolate children and young people who may represent an infection risk to others.
  • Consider changing open storage units to closed ones in the surgical wards to reduce the risk of cross-infection, especially in areas where clinical procedures take place, such as the treatment rooms.
  • Consider removing the bin in the children’s play area on Ward K3.
  • Consider reviewing the risk assessment for the fire escapes in the surgical wards to make sure they are secure enough to prevent children and young people leaving unnoticed and protect against people entering unobserved.
  • Consider the provision of a dedicated health play specialist and psychology resource to the critical care areas.
  • Ensure that the arrangements stated in the board papers received by the inspection chair on 22 May 2014 concerning the medical cover in HDU are monitored.
  • Ensure that staff report incidents on the NSU.
  • Ensure that staff effectively check and sign resuscitation equipment on the NSU.
  • Ensure that drug charts are appropriately completed on the NSU.
  • Review the learning disability service provision to ascertain roles and responsibilities of both nurses and doctors for adolescents and young people in transition.
  • Consider the Trust’s overall strategy, board reporting mechanisms and leadership responsibilities related to transitional care.
  • Take action to implement risk assessments in the outpatients department. The risk assessments would ensure the safety of children, young people, relatives and staff within the department.
  • Ensure staff in the outpatients department have the opportunity to receive clinical supervision via a Trust wide model.
  • Improve systems to ensure children and young people and their relatives and carers can make appointments in the outpatients department.
  • Ensure letters sent to children and young people and their parents and carers are in the appropriate community language for those people who do not speak English as a first language.
  • Ensure that staff in the outpatients department are effectively engaged in the development of the service.
  • Improve staff engagement across all services and improve the visibility of the board and senior team.
  • Improve the communication with staff to demonstrate a listening and responsive senior team.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 2 December 2013

During an inspection in response to concerns

Prior to this inspection concerns were raised with us that standards of quality and safety were not being met in the theatre department. We undertook a focused inspection in this area and across a number of wards within the surgical division. We did not include all areas of the Trust as part of this responsive review.

We found that all patients admitted to the Trust had their individual needs assessed on admission. We talked to patients, families and staff and found overall care was patient centred and their individual preferences and choices were taken into account in delivering the care provided. We found the ward areas to be clean, tidy and well maintained. Some comments were from patients and their families included

"I can't fault it, the nurses are amazing. Nothing is too much trouble, they are really

approachable. I've asked them the same thing lots of times and they are so patient. They explain everything to me. They have made a bad experience good. They arranged our stay at Ronald McDonald and have arranged for me to see a district nurse here. When I leave at night I know she is safe."

"Everything is fine, staff are attentive, know him well and what he needs and care for him like I do � so much so, I am happy to leave and go home. Staff are supportive of me too.�

"It has been a very emotional time but they are as supportive as they can be."

"I can't fault it, the nurses are amazing."

"Nothing is too much trouble."

We reviewed the staffing levels across each of the areas we visited and whilst overall staffing numbers on the ward areas were satisfactory, we found inconsistent numbers of staff to meet the needs of patients as a result of higher demand and staff sickness at the time of the inspection. We found staffing levels to be inadequate in the theatre department specifically.

We were concerned to find that staff working in the theatre suite had not followed published research and guidance at all times. These matters included best practice and checks and maintenance checks that should have been in place for essential equipment.

Prior to our inspection we were notified of a number of concerns relating to the support that staff were given by the Trust with particular reference to the theatre department. We found that significant improvements were needed to ensure staff were properly trained, supervised and supported at work.

We found that corporate systems and processes for quality assurance and improvement were in place. However the local implementation and monitoring of these processes in the theatre department was poor.

Inspection carried out on 24 January 2013

During an inspection in response to concerns

Prior to our visit, concerns had been raised with us regarding low staffing levels and the lack of availability of essential equipment on the High Dependency Unit at Alder Hey Children's NHS Foundation Trust. During our inspection, we spoke with staff in a variety of roles, as well as reviewing relevant documentation and observing the care and support provided to patients on the ward. We found that there was enough equipment to promote the health and wellbeing of people who use the service and there were enough qualified, skilled and experienced staff to meet people�s needs.

Inspection carried out on 28 November 2012

During a routine inspection

This was a scheduled inspection and during our visit we followed up an outstanding area of non-compliance identified at our last inspection, for which an improvement action was set. We visited three wards and the child protection unit during our visit and spent time speaking with patients and their families, as well as staff at a number in a number of roles.

We spent time speaking with nine patients and their relatives and invited them to share with us their experience and views. People we spoke with were mainly positive about their experience at Alder Hey Children�s NHS Foundation Trust Children�s NHS Foundation Trust. One patient we spoke with told us, �Everyone is brilliant� and a parent told us �This hospital is absolutely fantastic�. Patients and their families told us they had been given information at an appropriate time and in a way they could understand.

During our time spent on ward areas we saw staff treated patients, and their families, with respect and dignity. Parents we spoke with described staff at the hospital as �kind and gentle� and �caring and supportive�. People told us that if they had any concerns, they felt able to raise them with staff.

Staff we spoke with told us they felt well supported and we saw that progress had been made in the provision of staff support, as well as in the uptake of mandatory training across all staff groups.

Inspection carried out on 8 March 2012

During an inspection in response to concerns

During our inspection we visited two ward areas. We asked patients and their parents if they felt supported to make decisions about the care and treatments they had received. We were told they were given both written and verbal information to support their consent decisions. Medical and nursing staff explained procedures in a clear and understandable way, this included conversations about the risks involved for patients. We were told that staff were �honest about everything� their understanding was �tested� by staff and they were �encouraged to ask questions about the risks�. In particular we were told on the surgical ward that their consultant had spent a long time discussing the risks associated with their surgery and they welcomed this.

Parents told us the needs of their children were well met. They said they were satisfied with the support they had been given and that their child had always been treated with dignity and respect. We asked them to give us examples of this and they told us conversations and examinations were always undertaken in private, parents and children were given �time and space� to make decisions and staff always explained what they were doing in a �respectful manner�.

Parents told us that they had �confidence� in the nursing and medical staff. They said they had a �named nurse for each shift� and �they had received fantastic care�. They told us staff were �well trained�, they �communicated well and they enabled parents to be involved in all aspects of care�.