University Hospital Aintree

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. People always had enough to eat and drink to stay healthy. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

Patients told us staff had informed them about their plan of care. Patients said their nutrition and hydration needs had been met during the course of their wait in the emergency department, regardless of the area they were boarded or waited. Patients and their relatives who were waiting for treatment in the waiting area had access to jugs of water and hot drinks. All patients had access to hot food.

Staff told us they followed care pathways based on national guidelines in order to provide appropriate care and treatment to patients. They knew how to access clinical pathways and guidance when needed. Senior managers told us they participated in local and national clinical audits and findings were reviewed and shared.

Managers checked to make sure staff followed guidance. Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. Staff had access to policies and treatment guidelines, stored electronically. Policies and procedures were based on best practice from the National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine guidelines (RCEM). These were regularly reviewed and updated. Staff protected the rights of patients subject to the Mental Health Act and followed the Code of Practice. The trust had an agreement in place with the neighbouring mental health trust to provide psychiatric and mental health support to patients in the emergency department. This enabled staff to protect the rights of patients subject to the Mental Health Act and followed the Code of Practice. At handover meetings, staff routinely referred to the psychological and emotional needs of patients, their relatives, and carers.

Guidelines and protocols were available to staff to follow for the most common symptoms patients would attend the emergency department for. These were noted to be in date in terms of review. The staff were able to find and access clinical guidelines on the electronic record system and print them out as required to use as a source of reference. For example, patients presenting with diabetic emergencies.

Doctors, nurses, and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide safe care. Staff held regular and effective multidisciplinary meetings to review patients and improve their care. We saw multidisciplinary working with services, such as occupational therapy, psychiatric liaison, and diagnostics to identify the most appropriate care and treatment for patients.

Staff told us when a patient required admission, sometimes admission to the appropriate ward or clinical area was not possible as the ward was full. Patients had to wait either in the emergency department or in a temporary escalation space on the ward. Staff reported good access to specialist teams of staff who would be contacted to review patients. Generally, patients were assessed on a risk basis and patients with a higher acuity were reviewed first.

Staff were observed working well together as a team within the emergency department and putting the patients' needs first. Delays were sometimes experienced for patients who were referred to some specialties and required a speciality review. Nevertheless, it was seen that the medical team were working collaboratively by seeing patients who had waited in the emergency department for a long period of time as part of regular ward rounds. Staff highlighted that this was not consistent amongst all specialities, particularly surgical, which led to surgical patients experiencing delays of specialist care and treatment.

Once patients had been seen by the specific speciality, they became the responsibility of that team, with the ongoing support of the emergency department staff. The interprofessional standards of the RCEM were described to be in place, however it was not evidenced that these were upheld in practice. For example, any investigations ordered by the speciality team whilst the patient remained in emergency department, remained the responsibility of the emergency department to follow up.

Information packs were available to support patients living with learning difficulties or autism and staff sought to allocate them to quieter areas of the department whenever possible.

The region had a high population of homelessness and substance misuse; staff worked with the homelessness outreach and drug / alcohol misuse teams regularly to support people appropriately.

The SWAN (Palliative care - Signs, Words, Actions, Needs) team supported the emergency department to help advise end of life care planning and information about the team was available to people via notice boards.

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Emergency nurse practitioners received additional training to enable them to triage and treat patients with minor injuries. This diverted patients away from the emergency department and reduced overall wait times.

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The frailty team attended the emergency department as required to review and assess patients who could be cared for in the frailty unit. Chronic pain teams, learning difficulties teams and dementia support were available.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

There was limited evidence that the service monitored the effectiveness of care and treatment and used the findings to make improvements and achieved good outcomes for patients.

The service participated in some local and national clinical audits. Trauma services were delivered at University Hospital Aintree. However, there was limited evidence of the service participating in national audit submissions such as the Trauma Audit and Research Network (TARN).

The emergency department followed NICE guidance and hosted a GIRFT (Getting it right first time) visit.

The division used standardised electronic audits to measure the quality of nursing care delivered by services and specialties across the trust. The audits covered topics such as patient safety, nutrition and hydration, pressure ulcers, medicines management and infection control.

Consultants were able to describe the process of consent according to trust and RCEM guidelines. They explained that this was used for any procedure performed in the emergency department, including chest drains and fascia iliac blocks. Consent was recorded within the patient record and there were provisions and protocols in place pertaining to patients who did not have capacity to consent.

Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They supported patients who lacked capacity to make their own decisions or when experiencing mental ill health. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.

Staff gained consent from patients for their care and treatment during triage in line with legislation and guidance and this was clearly recorded in the patients’ records.

The service had effective systems to ensure staff assessed and managed the risks to people in relation to their mental health. A review of patient records showed a risk assessment of the patient’s mental health needs was completed or an appropriate plan to manage their mental health risks recorded.

When patients could not give consent, staff made decisions in their best interest, taking into account patients’ wishes, culture and traditions. The service had effective systems to ensure staff assessed the mental capacity of patients and recorded decisions made in service users’ best interest when applying to deprive the service user of their liberty. Managers monitored the use of Deprivation of Liberty Safeguards and made sure staff knew how to complete them.