University Hospital Aintree

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment we rated this key question requires improvement. At this assessment the rating remains requires improvement.

Staff managed medicines well and involved people in planning any changes. However, trust policy was not always followed when administering rapid tranquilisation medicines and some medicines were not always stored correctly. We fed this back to leaders at the time of inspection and assurance was provided that action was taken to address these areas. The division experienced higher levels of hospital acquired infections. There was lower achievement in some quality compliance audits undertaken.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. Staff understood and managed risks. The facilities had been adapted to meet the needs of people using them, they were clean, well maintained and any risks were reduced or mitigated. There were enough staff with the right skills, qualifications, and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care.

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

Peoples experience

We spoke with and provided questionnaires to 30 service users and relatives. Almost all the respondents were aware of how to raise concerns and felt confident they would be treated with compassion and understanding if they did so. People could provide examples where they had raised a concern that was acted upon and resolved.

Feedback from staff and leaders

Staff reported a positive learning culture based on patient safety events. They were confident to report incidents and raise concerns. Staff said actions were taken in a timely manner.

Managers informed us they shared lessons learned from incidents or complaints through daily safety huddles and handovers and regular meetings, emails and newsletters. Staff provided multiple examples of when improvements had been made following learning from patient safety events.

There was evidence that changes had been made because of staff feedback through incident reporting. There had been a 28% reduction in falls causing moderate or severe harm in the period 2023-24. The trust had implemented a new falls prevention care plan and an additional falls training package for staff in addition to a new digital falls team referral process. Falls alarms and equipment were used and staff linked in with the falls co-ordinators. Staff told us they had seen a reduction in falls since the implementation of these changes. There was a falls prevention nurse who was very present on the wards and a monthly falls strategy meeting where themes and actions were discussed. Staff and leaders understood the duty of candour and gave patients and families a full explanation and apology when things went wrong. The duty of candour requires registered providers to act in an open and transparent way with people receiving care or treatment from them.

Managers were able to share patient safety themes and trends relating to their ward and also within their medicine division. They told us that actions from safety alerts were implemented and monitored.

Staff members we spoke with across different wards and areas about learning culture, felt safety was a priority for the division and there was a culture of safety and learning.

This trust had recently been awarded National Preceptorship Interim Quality Mark for its comprehensive preceptorship programme.

Processes

The division had clear processes for staff to follow for reporting incidents. There were effective systems to review and investigate incidents. Risks were not overlooked or ignored. Managers and leaders discussed recent incidents at weekly safety meetings. They would escalate any incident that met the criteria for external reporting or may require a learning response. Any immediate learning was shared with staff and embedded into daily practice. Incidents were not closed off until all actions had been completed. Themes and trends of incidents, safety actions or learning would be escalated and discussed at a monthly trust wide shared learning and improvement forum to promote a safe culture. For example, the forum had most recently reviewed incidents associated medicines administration.

The service reviewed incident data regularly, from April 2024 to the end of September 2024, 4,485 incidents were reported in relation to medical care. The most frequent type of incident reported related to pressure ulcers, falls and medication incidents. The service had not reported any never events in the last 12 months. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.

We reviewed incident data for the service and found most cases were handled promptly after they had been reported.

The service reviewed incidents and completed patient safety incident investigations when required. We reviewed the last 5 incident reports completed which were detailed and had suitable improvement actions included.

The service had process in place which ensured mortality reviews were completed when a service user died.

The wards/areas we visited had noticeboards which provided examples of learning from incidents. Displays also provided reminders to staff to reduce the risk of incidents related to infection prevention and control, patients requiring specialist food preparation and pressure area care.

Peoples Experience

Patients being treated on the days we visited told us they felt safe and informed about their care. We saw how patients' information was shared with relevant health professions and that records were updated by multidisciplinary team members. Systems were in place to ensure sharing of patient information between relevant health professionals.

Feedback from staff and leaders

There were systems and processes in place to ensure continuity of care, including when people moved between services. Staff and leaders confirmed safety and continuity of care was a priority for patients with a collaborative approach to safety. We saw positive examples of patient flow management throughout the division of medicine. Patients requiring specific specialist treatment could be directly admitted to wards to ensure treatment was promptly started, for example those patients with a suspected stroke condition were directly taken to the stroke emergency assessment centre (SEAC) or the hyper acute stroke unit (HASU).

However, leaders acknowledged patients spent longer than they should on the acute medical unit (AMU) after a decision to admit had been made and some patients experienced discharge delays from ward areas due to waiting for medicines or transport. This was because of the number of patients requiring admission and fewer patients being discharged due to complex care needs and availability of services to support them on discharge.

Additional temporary escalation areas on wards had been modified for those patients who were admitted to the ward whilst they waited for a bed to become available. Leaders explained some of these areas were being redesigned to ensure patients had access to a nearby toilet, privacy, oxygen and call bells and only used for patients that met certain criteria, including those who were oxygen dependent.

Feedback from Partners

Partners and stakeholders provided positive examples of collaborative work with staff and supported patient admissions, and discharges. Community staff attended daily bed meetings. Discharge co-ordinators liaised with other agencies, especially for those patients with complex needs. Partners worked together with staff to prevent patients being readmitted into hospital unnecessarily.

Processes

The division had clear processes for effective communication and maintaining oversight of patient care and treatment from admission to discharge.

There was a multidisciplinary approach to board and ward rounds, safety huddles and multidisciplinary team meetings. Bed meetings were held three time a day. Attendance at these included operational and leadership staff.

Staff who worked in the bed flow team operated 24 hours every day to improve patient flow through the medicine division. A continuous flow model was in operation and patients were tracked throughout the division, including whilst waiting in additional spaces on a ward.

The division operated a streamlined service to avoid unnecessary admissions to the emergency department for stroke and cardiology patients who met the ward admission criteria. They would be reviewed on the ward by a consultant and onward care arranged. The frailty unit would admit patients directly from home.

Patient records were completed consistently. However, when specific pathways were deemed no longer appropriate for patients the supporting documentation was not always stopped. This meant that some patient observation charts and records appeared incomplete.

The division demonstrated positive and effective audit processes for patient safety and completed daily, weekly and monthly assurance audits.

Staff referred to a dashboard to track patients through the division and identify those ready for discharge and those waiting to be admitted.

Feedback from staff and leaders

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. They knew how to make safeguarding referrals and who they could contact if they had concerns.

Senior staff demonstrated a good understanding of the safeguarding processes including linking in with medical social workers. Staff mostly had a good understanding of deprivation of liberty safeguarding practices and when restraint would and would not be used. However, staff did not always follow trust policy when administering medicines to support people's behaviour.

Staff were confident in explaining that service users with medical emergencies in eating disorders (MEED) would be referred to the safeguarding team, a dietician and the mental health liaison service.

Processes

There were effective systems, processes and practices to make sure people were protected from abuse and neglect.

Safeguarding referrals had been completed appropriately.

Staff received safeguarding training specific for their role on how to recognise and report abuse. The training compliance rates for levels 1, 2 and 3 safeguarding training for adults and children were above the trust target for nurses (96% and 94%). However, medical staff were just below target (85% and 83%).

There were clear processes to guide staff when making a Deprivation of Liberty Safeguards (DoLS) when it is in the best interest of the person.

DoLS referrals reviewed had been completed appropriately for patients who had fluctuating capacity with a clear explanation documented.

Staff were committed to improving their knowledge of the Mental Capacity Act by undertaking further training and utilising the knowledge of the safeguarding link team for a greater understanding of patients who lacked capacity. Safeguarding information boards were available to all staff and learning regularly discussed at ward meetings.

Peoples experience

Patients we spoke with, who had been risk assessed, reported that staff were fully aware of their risk factors including diabetes, risk of falls, modified diet and mobility. Patients gave positive examples of how staff “were always available to help”, “assisted me to the bathroom”, and “they (staff) took me outside for fresh air safely” when using walking aids.

Patients waiting for a bed on wards received up to date and clear information and reported the communication to be "positive" and “regular”.

Feedback from staff and leaders

Staff were able to describe the process for escalation of a deteriorating patient in line with trust policy. They felt confident to escalate concerns to managers and medical doctors at safety huddles or board and ward rounds.

Staff understood the importance of recognising the signs of sepsis early and knew how to escalate a patient so they would receive treatment quickly. They followed the latest sepsis guidance.

Staff told us they performed daily enhanced observations to reassess patient risks. This included any new risks following new medication. Intentional rounding was completed every 2 hours for patients at risk of pressure ulcers. Managers were able to demonstrate that patient risk assessments were completed promptly, accurately recorded and regularly reviewed. Falls risk assessments were reviewed at least every 5 days if the patient’s circumstances did not change in the interim period.

Patient documentation reviewed evidenced patient risk assessment completion such as the requirement of a red tray for those who required assistance with food and drink. We saw that symbols were used above patient beds to identify any specific requirements the patient had.

Managers were able to describe their top risks for their ward and division and clearly articulate the mitigating plans to address each of these risks.

Patients' needs were prioritised and those patients receiving end of life care were reviewed by the pharmacist and the palliative care team first on ward rounds.

There was an effective structured handover process between staff changes which was regularly monitored and assessed for compliance. Audits were undertaken throughout the department to monitor compliance with policies and procedures.

Patients were assessed for risks resulting from falls, pressure area breakdown, absconding, and safeguarding.

Processes

Staff used the nationally recognised national early warning scores (NEWS2) tool to identify deteriorating patients.

The division had appropriate, clear and comprehensive standard operating procedures for the medical emergency team and resuscitation, sepsis and NEWS2.

Training records showed that compliance rates for levels 1 and 2 sepsis training were above the trust 90% target rate for all eligible staff. Adult and basic life support level 1 training compliance was 97% and above the trust target of 90%. However, compliance for level 2 and 3 resuscitation training was below the trust target at 79% and 78% respectively.

The division provided emergency measures sepsis audits completed between July 2023 and June 2024. Compliance rates against Advancing Quality (AQ) programme target - blood cultures taken diagnosis (53%), IV fluids given (68%) and care pathway commenced (66%) within a 1 hour of sepsis. NEWS2 recorded within 1 hour of hospital arrival (92%), antibiotics given (55%) and microbiology tests taken (53%) within an hour of sepsis diagnosis and senior review within 2 hours (60%). Leaders had recognised lower compliance rates, and this was captured in the divisional action plan to improve attainment.

Staff proactively followed processes to identify and manage risk for patient safety.

Patient records showed fully completed and timely risk assessments for each patient. This included, but was not limited to, fluid and food charts, behaviour ABC chart, body map for pressure ulcer and intentional rounding.

Patient risk factors were discussed at safety huddles, handovers and ward and board rounds to keep patients safe.

The trust had its own internal ward quality assessment programme. Each ward was assessed and given a score. Across the 21 wards in the medical division 14 were graded as red (79% or below) 2 were graded as silver (80-90%) and 5 were graded as gold (90-100%). For individual ward assessments for pressure ulcers 11 were graded as red (79% or below) 6 were graded as silver (80-90%) and 4 were graded as gold (90-100%). Each ward area had their own improvement plan as a result of the internal ward quality assessment programme which fed into the divisional improvement programme.

Staff followed appropriate policies and guidance when risk assessing a patient’s nutrition and hydration requirements.

People’s experience

Patients we spoke with on assessment told us the wards were a traditional layout and there was enough space in bay areas. They had access to toilets nearby and equipment to help them mobilise around with. Between May and August 2024, the Friends and Family Test (FFT) Inpatient satisfaction score was reported as 93.8% reflecting an improvement over the last 2 years. The National Inpatient Survey 2023 reflected a high level of satisfaction for patient experience with feedback placing the trust 10th of 120 acute trusts surveyed.

Feedback from staff and leaders

Staff reported on the whole they liked the layout of the wards allowed them to care routinely for 6-8 patients. Staff told us they had access to equipment when needed including resuscitation trolleys, hoists, falls equipment, computers and patient observation equipment.

Staff told us patient flow and discharge was a problem on some wards. One ward had identified that a delay in ordering patient take home medicines could have a significant impact on discharge times especially at weekends and had changed processes and improved communication with the pharmacy teams to minimise delays.

Staff told us that they had introduced a “power hour” at 3pm each day where all equipment and tables were cleaned, patient risk assessments were reviewed and medication checked.

A ward was being remodelled for use as a reablement facility during our visit. Staff told us that their views had been taken into account to make the environment more user friendly for its specific purpose. Storage areas for equipment had been remodelled so as not to clutter the areas around patient beds.

Observation

Entry to the wards was via an intercom system or electronic pass. A button was pressed to release the doors on exit.

The environment was well maintained. Corridors were clear of unnecessary equipment and fire exits were clear. Corridors and rooms were observed to be clean and fire extinguishers were labelled clearly and in date.

Equipment including hoists, clinical equipment and computers were observed to be cleaned and dated with ‘I am clean’ stickers and PAT tested. Emergency trolleys were spot checked on different wards and found to be sealed, cleaned all equipment inside was in date and complete.

Related check lists were completed in full. Oxygen cylinders were placed at appropriate points throughout all wards and observed to be in date. An oxygen cylinder on two wards was noted to be nearly empty and which we highlighted to the ward managers at the time.

Information boards above the patient bed area advised staff of any patient specific requirements such as nutritional needs or risk of falls.

Where infection prevention and control risks existed, information was displayed detailing the risk and minimum required level of personal protective equipment (PPE) required to enter the area/room. PPE was available and means of appropriate disposal noted.

Information boards on all wards were observed to be up to date and displaying required and actual staffing levels. Individualised notice boards were noted in ward areas providing information for staff, patients and relatives on topics such as end-of-life care, living with dementia, pressure ulcers, freedom to speak up, infection prevention and control and details of the Patient Advice and Liaison Service (PALS).

Hand gel was present throughout the wards and staff were observed to use it appropriately. Control of substances hazardous to health (COSHH) was observed to be stored securely and properly. Suitable COSHH risk assessments had been undertaken and were available to staff as a source of reference.

Call buzzers were observed to answered swiftly throughout all wards. We observed call bells were in easy reach of patients and placed in bathrooms suitable for patients to reach.

Computers were available for staff use to access patient records and record the care given. They were observed to be locked and charging when not in use.

A sample of medicine refrigerators were checked; we noted temperatures logs were recorded and completed in full.

Staff took pride in their ward areas and The Liverpool Quality Assessment (LQA) was observed to be embedded in each ward, with staff and leaders celebrating achievements and working toward the next goals.

Processes

Liverpool Quality Assessment audits were carried out in clinical areas across the trust and discussed monthly between matrons and ward managers. Actions were identified and supportive measures taken. Concerns highlighted at the time of audit were escalated to the ward managers and an improvement time frame given. For the (LQA) environmental and patient safety audits for 21 medical wards; 14 were graded as red (79% or below), 2 were graded as silver (80-90%), and 5 were graded as gold (90-100%).

Peoples experience

Patients we spoke with on assessment were asked to comment on staffing. We received mixed feedback as some felt there were enough staff on the wards and gave comments such as “there are lots of nurses and doctors” and “ample staff”. Others reported there should be more staff and gave comments such as yes “had to wait multiple times for my painkillers”, staff are “rushed off their feet” and “not enough at weekends”.

Feedback from staff and leaders

Ward managers reported that generally wards ran at the full complement of planned staff. When staffing was below the planned ratio or additional staff were needed, the on-call matron could be bleeped to reallocate staff from other clinical areas to support. Ward managers told us they have regular formal and informal staffing reviews. When these showed more staff were required there were mechanisms in place to escalate to the leadership team.

Staff reported staffing levels as generally OK, the workload was manageable, and they routinely received their breaks. Staff reported sometimes patients experienced waits to see medical staff during the evening and at weekends. This was because medical staff were contacted via the beep or telephone overnight and patient need was prioritised so those who were poorly were reviewed first. This resulted in a wait to be seen for some patients with less urgent needs. Staff told us medical staff and allied health professionals were approachable and that they contributed to ward rounds.

Wherever possible, patients requiring close observations were cohorted together in a bay and members of staff assigned to the bay at all times. Patients who required one to one care were allocated a staff member from a central resource on a risk basis. During periods when there were not enough staff available, ward staff stepped in; this presented a strain on the remaining staff members for patients requiring regular care Some wards had an activities room and co-ordinator and patients could come together to undertake activities to promote wellbeing and independence.

New starters and international staff spoke highly of the induction and preceptorship process. Staff told us they felt supported in their learning and development. Ward managers told us supernumerary time and learning was respected, and staff concurred. Senior managers told us the preceptorship programme had achieved the Gold Standard of the National Preceptorship Framework and was awarded the National Preceptorship Interim Quality Mark in March 2024.

Staff told us generally their senior managers were visible most days. Staff reported their ward managers were supportive, visible and approachable and they would be happy to raise concerns to them.

Ward managers had regular 1:1’s with matrons to outline areas of development and support individual learning. Clinical supervision was offered to all staff and an electronic app was used to record the meeting and sign off staff competence.

Observation

Staffing charts were clearly displayed on all wards denoting planned and actual staffing levels. Overall wards had the planned level of staff present on the days of inspection; there were occasional instances of staffing being slightly under the planned level. Managers acted appropriately where unanticipated absence had occurred, and staff were transferred from other areas where appropriate. There was a process in place to obtain additional staff for patients who required one-to-one care. Staff were observed to take their breaks on time.

Medical staff and allied health professionals were present and visible on the wards and liaised with nursing staff to enable treatment to be provided at optimum times for the patient. For example, patients were given their medicines prior to being supported to mobilise with physiotherapists. We observed patients interacting in bay areas and some wards had an activity area for patients to visit.

Staff training competencies were displayed on notice boards on most wards along with student skill levels. This supported staff to be confident asking students to participate in patient care, dependent on their level of training.

Processes

Training policies were available; there was a comprehensive list of mandatory training modules for each staff role. The trusts attainment in mandatory training was 89.66% at the time of assessment, with an upward trajectory which was just under the trust’s target of 90% compliance. The medical division was 91% for all staff groups.

Role and core specific training for medical and dental staff was also 91%.

Mandatory sepsis training for staff in specific roles (level 1) compliance was 95.68%, but for staff in non-specific level 2 roles compliance was slightly below 90% at 89.95%.

97% of nursing staff had completed Advanced Life Support (ALS) and 75% of medical and dental staff. There was an 83% compliance rate for completed appraisals for staff who worked in the medical division. Doctor appraisal rate was 91%.

Peoples experience

Patients we spoke with on assessment reported wards appeared clean and staff came into rooms and bays two or three times a day to clean them. Most could recall being screened for infections prior to or when they were admitted to the ward environment.

Feedback from staff and leaders

Infection prevention and control (IPC) issues or concerns were displayed at side room entrances or above beds and were kept up to date by staff. Ward managers told us electronic patient records allowed staff to view screening results prior to the patient being admitted to the ward, particularly if they were admitted via the emergency department or acute medical unit. This allowed staff to prepare for the patients’ admissions with the correct level of PPE being available.

Staff we spoke with did not raise any concerns related to infection prevention and control. All equipment was routinely cleaned and tagged overnight to ensure it was ready for use the following day.

Observation

Patient areas and corridors were observed to be clean and tidy. Cleaning records were up to date and staff were seen cleaning and tidying throughout visits to various wards. There were hand wash sinks placed throughout the wards and hand sanitiser and soap units present and full and available for use.

We observed where patients were being treated for an infection, or were at risk of infection, patient records contained the relevant detail to indicating the risk and required level of personal protective equipment (PPE) required. Staff were observed to follow IPC in place. We observed staff cleaning and tagging equipment to indicate when it had been cleaned.

Wards had noticeboards providing an update regarding IPC including information regarding recent cases of infection. Processes

The trust had appropriate policies for infection, prevention and control practices, including an outbreak control and ward closure policy and a decontamination of reusable medical devices policy.

The premises and equipment were kept visibly clean and hygienic. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly, and equipment was cleaned after each patient contact. We observed staff following infection prevention and control principles, including the use of personal protective equipment, effective handwashing and being bare below the elbows. Hand hygiene signage was displayed throughout the department.

The department monitored key metrics in relation to infection rates, including MRSA (Methicillin-resistant Staphylococcus aureus), MSSA (Methicillin-susceptible Staphylococcus aureus) and E. coli (Escherichia coli). All patients were screened for infectious diseases when a decision had been made to admit them or if they were displaying symptoms. Results were then made available to staff and any infectious cases were followed up by the sites infection prevention and control team.

The site was performing worse than the required trajectory for most infection KPIs and reportable infections (as of August 2024):

• MSSA bacteraemia – 2 cases against an internal year to date (YTD) threshold of no more than 12.5 cases.
• CDI (Clostridium Difficile) - 39 cases against a YTD threshold of no more than 33.75 cases
• E. coli – 63 cases against a YTD threshold of no more than 52.5 cases
• Klebsiella – 27 cases against a YTD threshold of no more than 16.5 cases

Staff undertook IPC training as part of mandatory training. Training compliance for level 1 was at 95% compliance, training compliance rates for level 2 were at 86%.

The ward Quality Assessment (LQA) infection control audits for 21 medical wards showed 5 were graded as red (79% or below), 9 were graded as silver (80-90%), and 7 were graded as gold (90-100%).

IPC link staff worked across the division and acted as advocates for good IPC practice. IPC resource packs were available in clinical areas to support staff and quarterly IPC meetings were held with link staff to review infection rates and share best practice.

Patient experience

Patients we spoke with varied in the length of time they had been on the wards from less than a day to 4 weeks. Over the last 12-month period the trust average length of stay for admissions into selected medical specialities with an overnight stay was 10.7 days which was longer than the benchmark of 6.9 days.

All patients reported that staff had taken time to get to know their wishes and preferences. For example, “pharmacy staff are on the wards daily” and “pharmacy staff give good advice”.

90% of patients reported they have been visited by their consultant or medical doctor every day with 10% saying weren’t sure this had been every day.

Pharmacy staff were available on wards for patients to discuss their medicines.

Staff could discuss the process for people who wanted to self-administer their own medicines.

Medicines were not always available on wards to be administered when prescribed.

Feedback from staff and leaders

Medicines reconciliation (the process of accurately listing a person’s medicines when they are admitted and comparing it to what has been prescribed as an inpatient) was documented on notes and being completed.

92.8% of people had their medicines reconciled within 48 hours of being admitted.

Staff described the training and competency checks they received to safely administer medicines.

Staff told us that pharmacy staff were visible on wards and would attend ward rounds and multi-disciplinary team meetings to provide medicines advice and support.

Observation

Medicines including controlled drugs (medicines requiring additional control due to their risk of misuse or diversion) and those used in emergencies were stored securely.

However, daily checks on expiry dates and stock levels of medicines used in emergencies were not always recorded and being completed as per trust policy.

Although some prescription stationary was stored securely, we found that outpatient prescription pads were not always securely stored.

Processes

Staff could explain the process to obtain advice about medicines from the Pharmacy team, including out of hours.

People’s allergies were recorded on the electronic prescribing system.

We reviewed the records for 1 person who was given rapid tranquilisation (use of an injectable medicine to help calm a person who is distressed). Guidance from the National Institute for Health and Care Excellence (NICE) recommended staff monitor and observe the person following rapid tranquilisation. The guidance was not followed; this placed the person at risk of harm. The trust’s policy to support staff when they had administered rapid tranquilisation did not provide enough detail to ensure the NICE guidance was followed.

Staff were not always recording when thickened fluids were being given to people at risk of choking or aspiration, so we could not be sure these were being administered as prescribed.

Covert medicines (medicines that are hidden in a person’s food or drink) did not always have administration instructions from a pharmacist so staff could administer medicines in a safe way.