Broadgreen Hospital

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

We rated this key question good. The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and patients were protected and kept safe. Staff understood and managed risks. The facilities 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. Medicines were managed well, and patients were involved in planning any changes to their care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. We scored the service.

We spoke with and provided questionaries to patients and relatives. All the respondents felt listened too and they could approach staff with questions about their care or concerns.

Staff described a positive culture where learning from patient safety events was routinely shared. They felt enabled to approach managers and matrons about concerns or incidents and were encouraged to report them via their internal electronic reporting system. Managers told us learning was cascaded to staff through daily huddles, team meetings and emails. Managers knew the risks relevant to their areas and were able to share patient safety themes and trends.

The medical division had clear processes in place to empower and encourage staff to report incidents consistently. The service regularly reviewed incidents at the weekly safety group meeting. As well as examining incidents this meeting also sought to identify incidents that were a 'good catch' and had prevented harm or risk of harm, and where good care had been identified. Staff we spoke with could provide examples of incidents described as ‘good catch’ and actions taken to prevent them happening again. For example, a plan of care in place to support people with swallowing difficulties, including how this was discretely shared with staff.

There had been zero Never Events or Patient Safety Incident Investigations (PSII) reported in Broadgreen Hospital in the 6-month period between July and December 2024. Never Events are defined as Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. Patient Safety Incident Investigations (PSII) are undertaken to identify what has happened and how it can be prevented from happening again, by learning and improving. The aim of a Patient Safety Incident Investigation is to understand: What happened. When did it happen. Why did it happen.

The division of medicine recorded 39 incidents with 21 learning responses. These included 9 After Action Reviews, 3 Multidisciplinary Reviews, 3 Falls Debriefs, 4 aSSKINg tools (The aSSKINg care bundle is a tool which guides and documents pressure ulcer prevention and many associated interventions aimed at reducing the risk of this often-preventable patient harm), 1 Safeguarding Section 42 review and 1 Mortality review. Ward 7 (reablement) reported the most incidents with learning outcomes including 2 falls reports and 2 pressure injuries. The Patient Safety Incident Response Framework was in date until March 2025 and provided staff with the process to follow when reporting and investigating incidents. The trust provided details of each learning response for Broadgreen Hospital. A dip sample of incidents was undertaken, and appropriate investigations had been completed, including duty of candour, or were ongoing. No themes of cause for concern were identified during our review of the incidents reported.

Themes and trends of incidents, learning and actions were discussed monthly at a trust wide meeting to allow shared learning across sites.

The wards and areas we visited had noticeboards which provided examples of how the ward had learned from incidents. Displays also provided ways staff could reduce the risk of incidents such as a reminder for staff on falls risk assessments to speech and language therapy (SaLT) assessment and referrals.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Patients we spoke with on the days of our assessment told us they felt informed about their care and felt they were looked after. They told us they saw consultants and doctors daily. Patients were happy with their environment and facilities available.

There were systems and processes in place to ensure continuity from one service to another was achieved. Staff told us they worked as a multidisciplinary team and referrals to physiotherapy, occupational therapy and SaLT teams were made during the initial assessment of the patient and we noted this routinely happened.

There was a multidisciplinary approach to board and ward rounds, safety huddles and multidisciplinary team meetings. Bed meetings were held regularly to assess need and capacity. Patient records were completed consistently and examination of randomly selected records showed thorough assessment of risk and onward referrals.

Each clinical area held regular multidisciplinary team meetings where patients’ discharge plans were discussed in detail. We observed a daily multidisciplinary team meeting led by a consultant and a representative of the nursing, therapy, and medical team as well as the community reablement team and the discharge hub team. Specialist nurses also attended to advise on specific patient needs, such as those living with dementia, and to ensure patients and carers had access to local support groups and teams. Patients’ needs were thoroughly assessed and discussed at the meeting; support for discharge was identified early and put in place. We observed how the team spoke respectfully and were knowledgeable about each patient's individual circumstances and took early action to prevent issues with discharge. This included liaising with social housing companies to ensure heating systems were working and door keys were available. Patients and their carers told us they were fully informed of how people would be supported to get to their place of residence and staff were available to ask questions and sort issues out.

Staff and leaders described the processes in place to manage the deteriorating patient and utilised national tools such as NEWS (National Early Warning Score) to identify patients with escalating care needs and transfer them appropriately.

Staff told us temporary escalation spaces (corridor care) were not used at this site as patients were admitted to a bed from their usual place of residence or transferred for reablement from either the Royal or Aintree hospitals. Broadgreen Hospital used the trust’s baseline assessments tools to assess patient need to ensure all care needs and risks were identified and met.

The division utilised patient feedback to inform change and had an audit system in place to monitor compliance, assuring their governance processes. The site actively participated in the Liverpool Quality Assessment which assesses each ward and grades them, according to performance in areas such as falls, risk assessment and infection, prevention and control. Criteria and guidance were available to staff to identify patients who were suitable for reablement across the trust and could be transferred to Broadgreen Hospital. Ward 8 also accepted patients assessed as suitable for a transfer with rehabilitation goals. We observed that referral systems worked appropriately depending on the area of care to meet the patients' needs and were clearly defined.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

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

A weekly safeguarding meeting took place in which specialist nurses would attend including the trust's learning disability and autism liaison nurse to support with individual cases.

Staff had a good understanding of deprivation of liberty safeguarding practices, could describe when restraint would and would not be used, and were observed delivering compassionate and sensitive care. Safeguarding team contact details and processes were displayed throughout wards to support staff in their work.

There were effective systems and processes in place to ensure patients remained free from abuse and neglect. Staff received safeguarding training on how to recognise and report abuse. Staff training completion for safeguarding adults was 98.3% and safeguarding children at 97% both of which were above the trust achievement compliance of 90%.

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

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider's restrictive interventions reduction programme.

Patients we spoke with reported that staff were fully aware of their risk factors, including risk of falls, and gave positive examples of being supported when mobilising. Patients understood their care plan and felt able to ask questions.

Staff were able to describe the process for escalation of a deteriorating patient in line with the trust policy. Staff gave an example of how they recently managed a collapsed patient outside the hospital and worked collaboratively with the nearby trust to stabilise the patient and get them to the emergency department.

Staff told us they contributed to ward rounds as part of the multidisciplinary team and were able to raise any concerns with medical staff and managers.

Patient documentation demonstrated comprehensive completion of risk assessments and in a timely manner.

Managers knew what their areas of risk were and the plans around them; these were discussed at managers' weekly meetings. The top risks identified were infection, prevention and control and the number of patients medically fit for discharge awaiting further support in the community and adaptations to housing. Related to the latter, staff told us the three local authority areas patients mainly lived in, had different criteria for discharge to support in the community which sometimes presented a challenge.

Staff used the nationally recognised national early warning scores (NEWS2) tool to identify deteriorating patients. NEWS is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes.

The department had appropriate, clear and comprehensive standard operating procedures for the medical emergency team, for resuscitation, sepsis processes and application of NEWS2 which were all current and in date.

Patient records showed fully completed and timely risk assessments for each patient. These were recorded daily within a short stay 7-day patient booklet. This included, but was not limited to, fluid and food charts, behaviour ABC chart, body map for pressure ulcer and international rounding. Environmental, ward/zone and falls daily check lists were fully completed.

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

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Patient risk factors were discussed at safety huddles and handovers, as well as ward and board rounds to keep patients safe. We saw that environmental, ward/zone and falls daily check lists were fully completed.

The trust had its own internal ward quality assessment programme, Liverpool Quality Assessment (LQA). Each ward was assessed and given a score. Of the 9 medical wards assessed at Broadgreen Hospital, 6 achieved silver compliance, 2 were gold and 1 was platinum. Four of the wards had improved to silver and above from red on the previous assessment undertaken.

The evidence showed a good standard. The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

Sixty percent of patients who completed our questionnaire and who we spoke with, said they felt there were more staff required. The remainder of patients said staffing was ok or that they were unsure. Patients spoke very positively about staff saying, “They could do with more staff because they work so hard” and “I couldn't find a doctor or nurse I would complain about.”

Staff stated that they had no concerns about their workload or the staffing levels but did report that there were occasions when they were understaffed through unavoidable absence. Staff explained that managers tried to fill those shifts where they could. Medical day unit managers told us they were experiencing a few staff shortages due to long term sickness, but they were covering these shifts by utilising bank shifts using their own staff and were expecting more staff to be assigned imminently. The site sickness rate was above the national average of 5.7% at 11% at the time of assessment which was mostly across the nursing and healthcare assistant staff groups. A further analysis of the reasons for long term absence was being undertaken at the time of assessment. Leaders reported the majority of short-term absences were due to illness associated with the winter period.

Staff told us they felt supported and that they received development opportunities. New starters said the induction/preceptorship programme was extremely beneficial and supportive. Students described a supportive environment where they were able to demonstrate the competencies required during ward placements and how they were encouraged to achieved enhanced competence. They described staff and leaders as being extremely supportive during placements and very much included as part of the ward team. Senior managers explained their preceptorship programme achieved the Gold Standard of the National Preceptorship Framework and was awarded the National Preceptorship Interim Quality mark in March 2024.

Staff told us they felt senior managers were visible and they could approach or raise concerns if they had too. Breaks were generally allocated and taken at appropriate times and staff told us they rarely missed their breaks. Staff were observed to take their breaks on time.

Staffing charts were clearly displayed on all wards denoting planned and actual staffing levels. Generally, the wards had the planned number of staff present on the days of our assessment with occasional incidents of staffing being slightly under the planned level. There was a process in place to obtain additional staff for those patients who required one-to-one care.

We observed staff encouraging patients to engage in activities and with other patients. However, on some wards we did observe patients remaining in pyjamas throughout the day, rather than dressing as part of their rehabilitation. It was not clear if this was through patient choice or not.

Training policies were available which comprised of a comprehensive list of mandatory training modules for each staff role. The trust’s attainment in mandatory training was mostly compliant with the trusts target of 90%. When broken down by role nursing and midwifery registered staff achieved 93.33%, Allied Health professionals achieved 90% compliance and medical staff sat slightly below target at 83.41%. Training figures for level 1 Sepsis training was 90.48% compliance which met the trust target. However, training compliance for level 2 was below target at 75%. The total number of staff identified for level 2 Sepsis training was 16, with 4 staff members overdue. The trust had provided a rationale explaining medical staff were below target because of long-term absence within one specialism.

To improve the compliance with basic life support training, staff who were overdue training were given priority to attend up and coming face to face training sessions. Duty managers had received additional training to deliver basic life support training across the Broadgreen Hospital site.

Appraisal compliance for medical staff at Broadgreen Hospital was 90.61% and for all other staff areas was 92.27%, meeting targets.

The Disclosure and Barring Service compliance rates for division of medicine was 100%.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The hospital Infection Prevention Control report for this site for Quarter 3 provided an overview of IPC audits carried out. Practice and environmental audits all achieved 90% and above. Hand hygiene which incorporated bare below the elbows fell under target significantly on 5 wards (1,2,5,9 and 10) which had increased by one ward in quarter 1. Cannula insertion was appropriately recorded 100% of the time in wards that returned results. However, it was noted some wards did not make any returns. This also applied to catheter insertion. Audits for ongoing catheter care showed 4 wards had not met the standard (ward 2,7,9 and 11). Catheter care had been noted as an ongoing risk for Broadgreen Hospital. Ward managers and infection prevention and control link staff were aware of the risks associated with infection prevention and control and a plan of action was in place that was overseen by the site infection prevention and control lead.

The trust monitored key metrics in relation to infection rates, including MRSA (Methicillin-resistant Staphylococcus aureus), MSSA (Methicillin-susceptible Staphylococcus aureus), E. Coli (Escherichia coli) and C. Difficile (Clostridioides difficile) and in December reported 0 cases of MRSA and MSSA and 1 case of C. Difficle. The trust acknowledged inconsistent performance in their January performance report.

Liverpool Quality Assessment infection control audit results across all wards received a silver or gold rating and boards displayed information including updates around recent cases of infection. Most wards had boards with IPC information for staff and visitors. Staff were keen to improve these internal ratings.

The medical care department provided evidence of cleaning schedules for each of the wards which provided information on the days cleaned, the tasks undertaken and highlighted when full cleans had been undertaken for the different rooms on the ward/area.

Of the patient records examined, one patient was identified as requiring care in a single room due to infection. This was documented, arranged and clear instruction given relating to treatment, care plan and required PPE.

The division actively supported the 'gloves off campaign' encouraging staff to use gloves appropriately and promote hand hygiene. We saw posters were displayed in clinical areas to encourage staff to comply with this.

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.

On the medical day unit, staff were observed to use appropriate PPE to prepare and administer medications. Hand gel and sinks were situated in appropriate locations and staff were observed using them properly. However, we observed staff not always sanitising or washing their hands when entering clinical environments.

Patients we spoke with told us they found the wards were clean, and staff were observed regularly cleaning. Most patients could recall being screened for infection prior to admission onto the ward. The division had processes in place to review patient screening results prior to admission.

Staff we spoke with did not raise any concerns relating to infection prevention and control. All equipment was routinely cleaned and tagged overnight to ensure it was ready for use the following day. The ward areas were visibly clear and free from clutter. Work areas were clean, and equipment was ‘clean tagged.’ Cleaning documentation was signed properly allowing oversight of tasks.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

All patients we spoke with told us that staff took time to get to know them and their wishes. Those patients who responded to our questionnaire told us they saw a doctor daily and this was reflected in the notes we examined.

No concerns were raised by staff about capacity to give time critical medicines and one patient fed back that he could access pain relief when he required it. Staff could describe quality improvement projects that led to a change in practice to ensure patients were administered their prescribed medicine on time.

Staff knew how and when to obtain medicines they didn’t routinely stock or how to obtain prescriptions out of hours. They knew where to find medicines policies and where to find information and support for time critical medications. Staff demonstrated knowledge in the handling of controlled drugs and documentation.

We saw staff assessed patients’ cognitive function and used strategies to support patients who were not familiar with their surroundings or were confused. The trust’s restrictive practice policy was followed when medicines were used to support a patient with an acute behaviour disturbance.

We found in most cases medicines were stored appropriately in the medicine's storage area on the ward. However, on one ward we observed one medicine cabinet unlocked whilst we were being shown the room by the ward manager. They error was corrected at the time.

We saw that emergency trolleys were checked regularly, and a process was followed to ensure this was done in a timely manner. Emergency medicine was checked in an appropriate way and an audit trail provided assurance this was done.

Processes were observed to be in place to promote the prescribing of oxygen and to support staff learning. Staff followed processes to check fridge temperatures and signed for this process daily with no gaps. Medication checks were completed in full in a similar manner. Trust Policies for safe administration are current and up to date.

Over last 6 months Broadgreen Hospital consistently dispensed take home medication in under 2 hours with the mean average time taking between 31 and 40 minutes. Site performance for audit of controlled drugs (CD’s) has remained consistent at 92%. However, a dip in compliance in the checking of daily balances of medicines was observed and had been escalated to site managers to oversee. Root cause analysis (RCA) of the identified dips coincided with times where staffing levels were not a full capacity. Oxygen prescribing training rate was improving and ongoing. Electronic records indicated that 94% of patients who received supplementary oxygen had it properly prescribed.