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 has changed to good.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service assessed and managed the risk of infection. Staff managed medicines well and involved people in planning any changes.

We have not awarded this service a score for Safe.

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

All staff we spoke with could articulate how they would raise incidents and were encouraged to do so by senior leaders. All staff knew what constituted an incident and could give examples of incidents that they had raised. Incidents were investigated by senior leaders within the emergency department. Senior leaders would share incidents and any learning with all staff through face-to-face meetings, newsletters and emails. From November 2023 to November 2024, 29 incidents with a harm grading of moderate, severe or fatal were reported for urgent and emergency care. The most frequent type of incident reported was related to delays to care and treatment. As a result, the trust had revised the existing footprint of the emergency department and to increase the number of patient beds in the majors department and opened up a same day urgent care facility where patients with less urgent symptoms could be reviewed by a GP, advanced nurse practitioner, physiotherapist or other health professional. This also diverted patients to a different waiting area that reduced overcrowding in the main emergency department waiting area.

We saw other examples of how the service had implemented changes which included identifying patients at high risk of falls and referrals to medical specialties as a result of learning from safety events.

Staff understood the duty of candour. There was an up-to-date duty of candour policy in place. We reviewed data for duty of candour compliance for urgent and emergency care between April 2024 and September 2024 and found 100% compliance, whereby staff contact patients and their representatives to apologise when care and treatment did not go to plan.

All staff we spoke with could articulate the complaints and compliments process and would proactively share this information with patients. Complaints were investigated by senior leaders within the service. Senior leaders would share complaints and compliments and any learning with all staff through face-to-face meetings, newsletters and emails. Information regarding the complaints and compliments processes was displayed throughout all areas of the emergency department with multiple channels for patients to follow. From June 2024 to November 2024 the service received 10 formal complaints and 189 concerns. We reviewed the trust performance of responding to complaints over a 6 month period prior to the assessment date and found that all complaints were investigated, actions identified and responded to within the appropriate timescale. Where learning was identified, actions were shared with staff.

Risks were managed by senior leaders within the service. The current top risks were overcrowding within the emergency department and wards were full meaning patients experienced delays to be admitted. We saw mitigation of overcrowding by additional temporary escalation spaces being utilised for patients to wait in, such as corridors, to relieve pressure on the main department.

We saw a positive culture of safety and learning. There was a no blame approach which empowered staff to report any issues without fear of negative consequences. Staff learnt from incidents and complaints as all information was shared by senior leaders. We saw examples of service users being listened to and their views being taken into account.

Between January 2024 and November 2024 there were 87,556 attendances to the emergency department. This was an average of 7,960 patients per month. This included patients attending by ambulance, self-attending or taken by the police or the prison service.

On arrival to the emergency department, patients who self-attended were seen by a clinical navigator who was a senior nurse. Patients explained their reason for attending and were either given a card for the same day urgent care unit (SDUCU) or emergency department. Patients streamed to SDUCU were then triaged by a trained nurse to determine their treatment plan. They were streamed into 4 categories; see and treat, minors, general practitioner or advanced clinical practitioner.

Patients streamed to the emergency department were triaged by trained staff using the Manchester triage system (MTS). There was support from a senior doctor or clinician who could assess patients and refer directly to clinical specialties or SDUCU. At times of high demand, additional clinical staff were deployed in the reception area to undertake a rapid assessment of patients to ensure they were seen in a timely manner.

The trust completed an audit review tool for triage. Between January 2024 and November 2024, the average time to triage for adults presenting with an acute physical condition was 11 minutes and for children it was 12 minutes. For patients presenting with an acute mental health condition the average time to triage was 10 minutes for adults and 13 minutes for children. These times were shorter than the Royal College of Emergency Medicine (RCEM) recommended standard of 15 minutes.

Patients told us their time to triage (assessment) had been timely and they had further tests undertaken quickly, such as ECG's (heart readings), blood tests and x-rays. Staff were alert to underlying symptoms that could be related to drug and alcohol intake and further tests were undertaken.

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Children were not routinely seen due to a local specialist Children's hospital in the locality, however all staff could articulate how they would manage a sick child prior to transfer.

Senior staff were allocated to all clinical areas to maintain oversight. There were board rounds and safety huddles undertaken throughout the day. All board rounds and huddles were led by senior clinicians and recorded as being completed. We observed that all huddles and board rounds contained all pertinent information to enable effective oversight.

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The service had 24-hour access to specialist mental health support. We reviewed previously undertaken mental health risk assessments and saw no errors or omissions. We saw previously recorded examples of patients being observed. However, data for the last 6 months showed that the trust had only referred 67% of patients to the specialist mental health service with a mental health condition within 1 hour.

The trust had been participating in an ongoing Royal College of Emergency Medicine (RCEM) Quality Improvement audit project which had resulted in an improvement in parallel assessments in each year's data set. Parallel assessment refers to a process where different healthcare professionals, or different parts of the UEC system, assess a patient's condition simultaneously or in a highly coordinated manner. This approach aims to expedite care and ensure patients receive the right level of attention quickly. The project ran from October 2023 to March 2024 and found that during this period, the rate of formally recorded parallel assessments had increased to 44%.

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We saw examples of senior clinicians reviewing patients that arrived by ambulance to ensure that patients were seen in clinical priority. The national standard set by the NHS is to achieve a handover within 15 minutes. Handovers within the service took longer than the national standard and were above the average for providers within the local system. Between January 2024 and November 2024, the average ambulance handover time was around 54 minutes. For the same time period, 517 ambulance handovers exceeded 30 minutes and were below 60 minutes wait for handover. The average number of ambulance handovers exceeding 60 minutes was 440.

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We saw examples of electronic discharge summaries being completed which contained all relevant information about the patients stay in the department if they were discharged home. Clinical responsibility for patients within the department was clearly defined. All patients within the department were cared for by the emergency department staff including those awaiting admission under other medical or surgical specialities, although this increased demand on department staff.

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Bed management meetings were held 3 times per day. The purpose of these meetings was to maintain oversight and grip of patient flow across the hospital. We saw that staff worked in multidisciplinary teams supported by discharge co-ordinators to facilitate discharge home. Patients could be referred to community re-ablement teams to offer short-term packages of support.

Staff had training on how to recognise and report abuse and they knew how to apply it. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Nursing staff training compliance for level 1 and 2 adults and children was 93%. However, nursing staff compliance for level 3 adults and children was 76%. Leaders were aware of this and training was being prioritised for appropriate staff to attend.

Medical staff training compliance for level 1 and 2 adults and children was 95%. However, medical staff compliance for level 3 adults and children was 68%.

The trust had designated safeguarding practitioners who supported in completing risk assessments for patients who presented a risk to staff and other patients.

We saw examples of staff assessing patients' capacity and documenting it within the patient notes. All clinicians were able to articulate how they would assess a patient with mental health issues including the appropriate risk assessment. Mental Capacity Act training was incorporated into the safeguarding training modules.

Nursing staff compliance for The Oliver McGowan Mandatory Training on Learning Disability and Autism was 86%. Medical staff compliance was 80%. This was below the trust target of 90%.

Some people attending the department said they had experienced long waits to be admitted to a ward and were therefore at risk of deteriorating. There was a standard operating procedure (SOP) for patients cared for in temporary escalation spaces on the corridor. During our assessment, we saw 15 patients being cared for in a corridor within the emergency department; this presented difficulties in staff observing patients due to the layout of the corridor. Trust data showed that 5,303 patients had received corridor care between September 2024 and November 2024. In addition, from October 2024 up to the date of our assessment, 864 patients had spent more than 12 hours on a trolley on the corridor and 233 patients had spent more than 24 hours. Healthcare assistants were allocated to care for patients in the corridor and completed 2 hourly intentional rounding. Audit data showed that the service had achieved an average of 89% compliance for 2 hourly intentional rounding for the last 3 months. Patients on the corridor had access to a dedicated room for staff to support with their personal care and regular food and drink was offered to patients. Call bells had been installed and were accessible to patients on the corridor.

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The trust temporary escalation process outlined actions for ward areas to undertake to improve patient flow and discharge to support the emergency department. We observed patients, referred for specialist care and treatment, being transferred from other hospitals via the emergency department. This meant that patients requiring specialist care spent long periods in the department having tests completed before being admitted to the relevant speciality.

Staff described working as a team to provide care to patients and that they very rarely turned people away. Staff had access to a psychiatric liaison team to assess a patient's mental health concerns and they attended a handover meeting every morning. They would aim to see a patient within an hour to evaluate the patients' needs and provide crisis management. However, there were delays in responding on occasions. For patients who attended frequently with mental health conditions, a care plan was in place to support their care.

Staff completed risk assessments for each patient on admission / arrival, using a recognised tool and reviewed this regularly, including after any incident.

There was a flag on the electronic patient record system that alerted staff if a patient had a safeguarding or mental health concern. We saw examples of patient passports being used within the emergency department to enable awareness to staff of specific patient need.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them. Observations of vital signs were recorded by staff and the national early warning score (NEWS2) was calculated. These were recorded electronically. The service had a clear escalation policy for the deteriorating patient. Between June 2024 and November 2024, the service achieved 86% compliance for NEWS2.

Staff knew about and dealt with any specific risk issues such as possible sepsis. The emergency department had a dedicated sepsis treatment room with all necessary documentation and equipment including medicines for the rapid assessment and treatment of sepsis. There is national guidance for how quickly patients should receive treatment for sepsis based on their presentation. However, between August 2024 and September 2024, the trust achieved 77.5% compliance for antimicrobials given within 1 hour for severe diagnosis and 3 hours for moderate diagnosis.

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Staff completed sepsis training as part of their mandatory training requirements. Nursing staff and medical staff compliance for Sepsis training within the urgent and emergency care service was 89%.

Patients felt the waiting area was busy and lacked space to accommodate the amount of people attending the emergency department at times. Corridor patients acknowledged the environment they were located in was not designed to meet their needs. For example, patients reported the environment not being ideal due to the noise, the amount of people walking by and poor access to bathrooms.

During our assessment we observed patients on trolleys situated on the corridor. When the emergency department was at full capacity, patients were cared for in areas that were out of line of sight for staff. Staff members told us this was a regular occurrence. All patients on trolleys in the corridor were cared for on pressure relieving mattresses.

When patients were cared for on trolleys in non-clinical areas, sufficient staff were allocated to the area. We saw private areas being used for these patients if further assessment or personal care was required. All trolley spaces had access to the nurse call system, and we observed staff responding in a prompt and timely manner. All trolley spaces had supplementary oxygen, and we observed staff regularly checking and replacing oxygen cylinders as required.

The service participated in weekly clinical environmental inspection audits. Audit results from the last 3 months showed that the service achieved 91% compliance. However, the audits identified repeated concerns such as fire exits not being clear and accessible, issues with the sluice room not being organised and equipment not being appropriately cleaned and labelled.

A fire risk assessment was carried out by a third party in December 2024 and identified numerous concerns including patients being boarded on the main hospital corridor due to emergency department pressures. The risk assessment also identified concerns relating to housekeeping and fire exits being obstructed. The risk assessment was categorised as moderate risk. As a result the trust stopped using the main corridor as a temporary escalation space and reconfigured a corridor within the emergency department. At the time of assessment we saw that fire exits were accessible.

We observed that all handovers were undertaken in a designated area where patient confidentiality could be maintained. All areas of the emergency department were physically clean. However, we did note multiple areas of paint loss on walls in corridor areas which would prevent effective cleaning.

The designated mental health assessment room and adjacent facilities were fully Psychiatric Liaison Accreditation Network (PLAN) compliant.

All equipment was well maintained, suitable for the intended purpose, tested, secured and used properly. All clinical and non-clinical waste was managed appropriately.

The trust was in the process of reconfiguring the emergency department estate to increase capacity and manage additional overnight and weekend pressures.

Results from the quarter 3, 2024/2025 Control of Substances Hazardous to Health (COSHH) audit, showed that chemicals were stored correctly in all areas of the emergency department. However, there was no COSHH risk assessment for the Acute Medical Unit (AMU) and x-ray department.

Nursing staff kept up to date with their mandatory training. At the time of our assessment, mandatory training compliance for nursing staff within the urgent and emergency care service was 92%. This was above the trust target of 90%. However, mandatory training compliance for medical staff was 86% and below the trust target.

The mandatory training offer for staff was comprehensive and met the needs of patients and staff. The training covered topics such as infection prevention control, moving and handling, fire safety, equality diversity and inclusion, health and safety and information governance. All nursing staff we spoke with had undertaken core competencies when first employed within the emergency department. All newly appointed staff were able to describe a period of being supernumerary when first in the emergency department.

Staff received life support training for adults and children, however not all staff completed it. The nursing staff compliance rate for basic life support (BLS) was 100%, paediatric basic life support (PBLS) was 77% and immediate life support (ILS) was 77%. The medical staff compliance rate for PBLS was 64%, ILS was 66% and advanced life support (ALS) was 78%.

Senior leaders calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants needed for each shift using a safer staffing tool. University Hospital Aintree emergency department used the SNCT (Safer Nursing Care Tool) acuity and dependency tool twice a year to provide evidence-based decision making on workforce requirements. There were 5 levels of care with associated descriptors to determine the level of care a patient needed, which allowed staff to measure how unwell a patient was and how reliant they were on nursing care to have their needs met.

We reviewed staffing fill rates from September 2024 to November 2024. For registered nurses, the average fill rate during the day was 104% and 98% at night. For unregistered staff, the average fill rate was 108% during the day and 103% at night. We observed the required number of nurses working in each clinical area.

The service had enough medical staff. The rota ensured that there was a minimum of 18 hours resident consultant cover during the week and 16 hours of resident consultant cover at the weekend. This was supported by the on site trauma team lead cover 24 hours per day 7 days per week.

Leaders covered staffing gaps with agency workers, and called in additional staff where possible, particularly during periods of high demand. From September 2024 to November 2024, around 17.3% of shifts were filled by agency nurses. For the same time period, 27% of shifts were filled by locum staff. All agency staff we spoke with told us that they had a full orientation on their first shift in the emergency department.

The service had safe recruitment practices to make sure all staff were suitably experienced, competent, and able to carry out their role. Staff underwent induction and completed competency-based training. We reviewed the Safe Recruitment and Selection policy, Temporary Staffing policy, Safer Staffing policy and the Local Induction Safety Checklist; all were up to date and appropriate in content.

At the time of our assessment, the vacancy rate for nursing staff was 15.9%. The consultant vacancy rate was 1.9 whole time equivalent (WTE). The rest of the medical staffing workforce was over established by 2.8 WTE.

From June 2024 to November 2024, the average staff turnover rate for this service for nursing staff was 3.4%. The average staff turnover rate for medical staff was 18.4%.

The sickness rate for nursing staff was 6.8% and medical staff was 3.6%.

Managers did not always support staff to develop through yearly, constructive appraisals of their work. The data provided showed that 64% of nursing and medical staff across acute and emergency medicine had received an appraisal in the last 12 months.

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 (IPC) principles, including the use of personal protective equipment, effective handwashing and being bare below the elbows. Hand hygiene signage was displayed throughout the emergency department. All waste and clinical specimens were observed to have been managed appropriately.

The emergency 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). There were no instances of MRSA, MSSA or E. coli reported for Quarter 3 2024. 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.

Patient-Led Assessments of the Care Environment (PLACE) results at the time of the assessment showed outcomes for cleanliness at 100%.

Infection prevention and control level 1 training compliance was 97%. Nursing staff compliance for level 2 infection prevention and control was 94%. Medical staff compliance was 77%.

The emergency department carried out numerous IPC audits monthly. Results from the September 2024 to November 2024 audits showed:

• Hand hygiene compliance was 40%.
• IPC practice and environment compliance was 97%.
• Cleanliness compliance was 96%.
• PVC/Cannula insertion compliance was 83%.
• Urinary catheter insertion was 100%.

The audits identified hand hygiene and IPC practices on the corridor as areas for improvement.

There were 2 IPC related entries on the trust risk register. Inability to isolate patients due to lack of available side rooms and facilities, resulting in risk of cross contamination and infection. This had been on the risk register since March 2024. Limited access to hand washing facilities on the emergency department corridor had been on the risk register since June 2024.

High-risk medicines were identified and recorded upon admission to ensure appropriate monitoring. There was timely accessibility to time-critical medicines such as medicines for the treatment of Parkinson’s disease. Records demonstrated that medicines were given at the correct times. People’s medicines allergies and regular medicines were recorded upon arrival to the emergency department and Summary Care Records were used to support this process. However, we saw one instance where an antibiotic was prescribed to a person without their allergy status being documented. We also saw this occur at another site at the Trust. Risk assessments for venous thromboembolism (VTE) were completed promptly and medicines were prescribed appropriately. Records relating to the administration of insulin were correct and in line with the Trust’s policy. Whilst the prescribing of oxygen had improved at the Trust, there were still some instances where oxygen had not been prescribed. Medicines were stored safely in all areas where people were being cared for. For medicines requiring refrigeration, temperatures were recorded regularly and appropriate action taken if temperatures were not within the appropriate range.