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Archived: Wythenshawe Hospital Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 June 2016

Wythenshawe Hospital is one of two locations providing care as part of University Hospital of South Manchester NHS Foundation Trust. It provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, a neonatal unit, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services.

We carried out an announced inspection of Wythenshawe Hospital on 26-29 January 2016 as part of our comprehensive inspection of University Hospitals of South Manchester NHS Foundation Trust.

Overall, we rated Wythenshawe Hospital as ‘Requires Improvement’. However, we rated the service as good for children and young people services, end of life and critical care. We found that services were provided by dedicated, caring staff and patients were treated with dignity and respect. However, improvements were needed to ensure that services were safe and responsive to people’s needs.

Our key findings were as follows:

Cleanliness and infection control

  • The trust had infection prevention and control policies in place which were accessible to staff.

  • We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.

  • Overall, patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.

Nurse staffing

  • Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.

  • Across medical services nurse staffing levels were variable. There were vacant posts on all wards that were being filled by either staff working extra hours, or bank and agency workers. Staffing had been identified as a risk on the divisional risk register and all staff highlighted this as an area of concern. Actions had been identified to mitigate the risk.

  • The neonatal unit did not consistently meet standards of staffing recommended by the British Association of Perinatal Medicine (BAPM). Additionally, nurse staffing levels on starlight ward did not reflect Royal College of Nursing (RCN) standards; an acuity tool on the starlight ward was not in use at the time of the inspection.

  • There were four vacancies in paediatric nurse staffing within the emergency department at the time of the inspection but recruitment was in progress.

  • Within the diagnostic and imaging department there were challenges with regard to recruitment and retention of nurses and radiographers within the diagnostic and imaging department.

Medical staffing

  • There was a reliance on locums within the emergency department to fill 28% of medical shifts. There were four vacancies in paediatric nurse staffing within the department but recruitment was in progress.

  • During our inspection we found the critical care services had a sufficient number of medical staff with an appropriate skill mix to ensure that patients received the right level of care.

Leadership and Management

  • The senior team, in the majority of core services, were visible and accessible and well known to the staff.

  • There was a lack of engagement and leadership from senior clinicians within the maternity services. This lack of engagement had resulted in a significant delay in investigating incidents and reviewing and updating clinical guidance.

  • Within children and young people’s service the local leaders on the ward and units were visible and managers were actively involved in the day to day running of the paediatric areas. However we noted that managers undertook clinical duties to increase staffing numbers which consequently meant they had limited time for managerial duties.

Access and Flow

  • Access and flow was identified as a concern in the emergency department. The ED had not met the target to see, treat, admit or discharge patients within four hours at all in the last 12 months. Initiatives were in place to try to address this.

  • Bed occupancy rates, delayed transfers of care and discharges had an impact on the flow of patients throughout the hospital due to the demand for medical services. Between January 2015 and December 2015, bed occupancy rates across medical services were over 100%, ranging from 101% to 104%. Due to the shortage of beds in medical services, patients were being treated on wards not best suited to their needs (also known as outliers). The trust ensured that all outliers were seen by a consultant, and each ward had a named consultant to carry out this role on a daily basis.

  • There were challenges with access and flow through surgical services; however services were responsive to individual needs of patients. We observed numerous examples where staff adapted services to the needs of patients, including delivering medication through sign language to a deaf patient. The trust had considered the changing needs of its population and had trained staff to be ward leaders in care for people with dementia.

  • Within critical care there was insufficient capacity to meet patient need which meant patients were not always admitted promptly to receive the right level of care. The high bed occupancy levels in the critical care services meant operations were cancelled due to the lack of available critical care beds.

  • As part of the trust’s escalation policy, patients were transferred to the main ‘theatres recovery area when there were no critical care beds available. There had been 59 occurrences of patients being nursed overnight in theatre recovery from April 2015 to October 2015. Patients kept overnight in recovery were assessed by critical care consultants. However, they were cared for by recovery nurses that had not completed all the relevant competencies to treat critically ill patients. There were plans in place to provide training for recovery staff by the end of March 2016.

  • Patients were not always discharged from critical care in a timely manner due a lack of available ward beds and capacity constraints across the trust. ICNARC data up to September 2015 showed the number of reported delayed discharges (within and greater than four hours) was worse than other comparable units nationally. The data showed the delayed discharges were consistently 10% to 20% above the average since January 2013.

  • The smooth flow of patients on ward F16 was interrupted by limited access to sonography. The shortage of scanning sessions available in the early pregnancy assessment unit led to unnecessary admissions to the ward.

  • Diagnostic waiting times were worse than the England average from August 2014 onwards, with performance particularly poor during the second half of 2014. Between June 2015 and September 2015 the proportion of radiological investigations reported on within 10 days ranged from 68% to 75.5%. The did not attend (DNA) rate at Wythenshawe Hospital was higher than the England average each month since February 2015.

We saw several areas of outstanding practice including:

  • The bereavement midwife had been nominated for the national Butterfly awards two years running. These are awards celebrating survivors and champions of baby loss. The bereavement midwife was also runner up in the Royal College of Midwifery awards for her work providing bereavement support.

  • A rapid access clinic had been introduced for menstrual disorders and post-menopausal bleeding to meet demand and allow for the development of innovative out-patient treatments such microwave endometrial ablation and hysteroscopy sterilisation.

  • The cystic fibrosis team were awarded the quality improvement award by UK cystic fibrosis registry annual meeting in July 2015. The paediatric CF team won the first National Cystic Fibrosis Registry Quality Improvement Award in recognition for innovative use of the Port CF database, which provided focussed and early intervention to prevent further deterioration in their patient’s condition.

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

Importantly, the trust must:

In Urgent and Emergency Care:

  • Ensure equipment checks in resuscitation areas are completed daily in line with trust requirements with a clear pathway for reporting associated concerns and actions such as missing equipment and subsequent replacement.

  • Ensure staff appraisal rates consistently meet the trust target.

  • Ensure the safety of reception staff at all times and take steps to mitigate current risks associated with the reception environment such as no protective screens and open desk areas.

  • Ensure that the temperatures of fridges storing medicines at low temperature, are recorded in line with guidance on a daily basis, and that required issues are consistently reported.

  • Ensure action is taken to remove the risk of ligature from ceiling vents in the mental health room, in line with guidance from the Royal College of Emergency Medicine (CEM6883 Mental Health in EDs toolkit February 2013)

  • Consistently improve patient waiting times in line with Department of Health targets.

In Medicine:

  • The trust must ensure that staffing levels are appropriate to meet the needs of patients across the medical services and ensure there is an appropriate skill mix on each shift.

  • The trust must ensure that all records are stored securely when not in use.

  • The trust must take action to improve the bed occupancy rates across medical services to ensure the safe care and treatment of patients.

In Maternity:

  • The trust must improve mandatory training for midwifery staff in terms of safeguarding level three training to ensure it is in line with the trust target.

  • The trust must ensure all clinical policies are regularly reviewed and kept up to date.

  • The trust must ensure incidents are investigated in a timely manner to ensure lessons are learned and recommendations implemented.

In Children and Young People:

  • The service must ensure safe staffing levels are sustained in accordance with National professional standards and guidance.

  • The service must ensure that staff are reporting risks and incidents to the senior leaders of the service actions being taken in a timely manner.

  • The service must ensure that all treatment, assessments, diagnostics and any other care relating to the patient is recorded appropriately in patient records.

  • Ensure that transition arrangements for children between 16 and 18 years meet the needs of the individuals without prejudice.

In addition the trust should:

In Emergency Department:

  • Review the security of the paediatric ED entrance to ensure children are safe at all times
  • Introduce recording of completed cleaning to ensure contemporaneous records are available
  • Improve the cleanliness of areas found to have dust and debris on the floor (store room and mental health room)
  • Review the storage of equipment in open packaging, or without packaging in the resuscitation area.
  • Improve the uptake of mandatory training for medical and nursing staff where there are pockets of low compliance.
  • Reduce locum usage in the ED whilst maintaining appropriate staffing levels.
  • Improve service for patients and relatives in relation to food and refreshments in the ED.
  • Put appropriate actions in place to improve services following local or national audit and ensure that relevant staff are aware of findings.
  • Review the role of the discharge lounge in ensuring access and flow through the ED.

In Medicine:

  • The trust should take action to ensure that all necessary patient risk assessments are completed across medical services in accordance with the National Institute for Health Care Excellence (NICE) guidance.

  • The trust should ensure that all ligature risks are identified and risks mitigated to ensure patients at risk of harming themselves are protected.

  • The trust should ensure that patients are discharged as soon as they are medically fit.

  • The trust should ensure that patients are not moved ward more than necessary during their admission and are cared for on a ward suited to their needs.

  • The trust should take action to ensure that all staff receive annual appraisals.

  • The trust should take action to provide the necessary mandatory training for medical staff.

  • The trust should cascade major incident planning information to all staff across medical services.

In Surgery:

  • The provider should ensure that there are adequate numbers of suitably qualified staff to ensure safe patient care and maintain a safe environment.

  • The provider should ensure that it develops a recovery plan to address the bed capacity difficulties that surgical services are experiencing, in order to resolve the high number of late cancelled surgical procedures and improve referral to treatment times.

  • The provider should ensure that any difficulties with clinical leadership, including nursing and medical leaders, should be fully resolved in order that all surgical services should be well-led.

In Critical Care:

  • Take appropriate actions to reduce the number of delayed discharges.

  • Take actions to ensure patients kept in theatre recovery receive appropriate care and treatment.

In Maternity:

  • Consider the number of scans available to prevent women having to be admitted to the ward or to the emergency department after 18:00.

  • Improve the uptake of mandatory training for medical and nursing staff.

  • Review all guidance and ensure it is in date and fit for purpose.

  • Review the number of sonography sessions available in the early pregnancy unit to prevent unnecessary admissions to the ward.

  • Staff should receive feedback from incidents.

  • Review midwifery staffing levels to reach trust targets with midwifery staffing ratios.

In Children and Young People:

  • The service should consider how sufficient time for the ward manager to perform managerial tasks associated with the role can be supported.

  • The service should consider protecting nurse training time to develop staff.

  • The service should consider improving their CAHMS pathway.

  • The service should consider training on incident reporting with emphasis on informing staff what the trust constitutes as an incident.

In End of Life:

  • The trust should ensure that all staff groups have access and are trained to use the trusts electronic reporting system.

  • The trust should consider requesting feedback about the quality of mortuary services from partner agencies such as funeral directors.

  • The trust should consider developing a work schedule in relation to narrowing the gap between preferences and place of death.

  • The trust should set targets for completing all action plans.

  • The trust should consider making testing major incident plans.

  • The trust should consider ensuring audits reach the appropriate target audience so that senior clinicians are able to comment on their area of responsibility such as use of the individual plan of care booklet.

  • The provider should ensure all doctors who sign DNACPR include their position and GMC number as requested on the form.

  • The trust should ensure the leadership structure for all services involved in palliative and end of life care is clearly defined.

  • The trust should consider completing a staff survey to enable staff to comment on the quality of the service and future developments.

  • The trust should consider making the use of the most effective end of life care planning tool mandatory or develop a policy and risk assessment which supports two systems currently in use.

  • The trust should review the medication policy to ensure management of prescription forms in the community is in line with best practice guidance.

  • The trust should ensure the pain scoring assessment tool is used in conjunction with the pain plan of care.

In Outpatients and Diagnostic Imaging:

  • The trust should take action to ensure that equipment is available and fit for use with minimal disruption to the service.

  • The trust should ensure a record is maintained of the minimum and maximum of fridge temperatures for each medication fridge.

  • The trust should take action to address the issue of x-ray requests being completed using the log in of another referrer.

  • The trust should put measures in place to allow patients to book in to outpatient and diagnostic areas without being overheard.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 30 June 2016

Effective

Good

Updated 30 June 2016

Caring

Good

Updated 30 June 2016

Responsive

Requires improvement

Updated 30 June 2016

Well-led

Good

Updated 30 June 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 30 June 2016

There had been a backlog of incidents requiring investigation and a lack of clinical engagement in the investigation process. At the time of our inspection, the service was receiving reports from the investigation of incidents that had occurred 20 months ago. This meant that there was a significant delay in the service understanding and sharing the learning arising from these incidents and a delay in making improvements to enhance the safety of the service as a result. We found a lack of incident reporting and a downward trend in number of incidents reported in a 12 month period.

There had been a long standing concern within maternity services in terms of safeguarding children’s level three training. At the time of the inspection compliance for the service was below the trust target.

Mandatory training compliance was slightly worse than the trust target for maternity services.

Concerns were raised in terms of the senior medical rota on delivery suite. Staff felt that the management of patient risk was fragmented and there was little continuity of care due to the rota being split into four separate shifts. We were informed this could lead to care plans changing more frequently and clinicians delaying making a decision until the next doctor took over.

The ratio of midwives to births within the service at the time of our visit was one midwife to every 31 births, which was worse than the England average and trust target. The service had not been compliant with this target since February 2015.

The smooth flow of patients on ward F16 was interrupted by limited access to sonography. The shortage of scanning sessions available in the early pregnancy assessment unit led to unnecessary admissions to the ward.

There was a lack of engagement and leadership from senior clinicians within the service. This lack of engagement had resulted in a significant delay in investigating incidents and reviewing and updating clinical guidance.

A review of the services and of medical staffing in June 2015, conducted by the new Clinical Director concluded ‘ineffective clinical leadership had resulted in a fragmented disorganised service with wide variation in practice, with no cohesion between the senior clinicians and no significant professional development or succession planning’.

The unit governance information and incident update had not been distributed since June 2015 and there was no group for reviewing and updating clinical guidelines. We subsequently saw no evidence of lessons learned being shared with staff.

Medical care (including older people’s care)

Requires improvement

Updated 30 June 2016

We found concerns in relation to safety due to nurse staffing numbers, the storage of records, the completion of risk assessments, and responsiveness of the service due to bed occupancy.

Nurse staffing levels across the medical wards was variable. All wards we visited had vacancies that were being filled by either staff working extra hours, or bank and agency workers. Staff were regularly moved to cover other wards leaving their own ward short of staff. All staff we spoke with reported concerns about staffing levels across medical services. All managers reported staffing levels to be a risk and it was on the divisional risk register. There were actions identified to mitigate the risk, such as a rolling programme of recruitment and rotas planned well in advance by ward managers and using health care staff to increase the amount of staff on the wards. However, this could potentially lead to a risk of an imbalance of skill mix, and did not mitigate the need for trained nurses to be on shift to provide the care and treatment required.

There were ligature risks in patient bathroom facilities. At the time of inspection these risks were not assessed in order to protect patients who were at risk of harming themselves.

Bed occupancy rates, delayed transfers of care and discharges had an impact on the flow of patients throughout the hospital due to the demand for medical services. Between January 2015 and December 2015, bed occupancy rates across medical services were over 100%, ranging from 101% to 104%. This meant that there were more patients needing medical beds than they actually available. Due to the shortage of beds in medical services, patients were being treated on wards not best suited to their needs (also known as outliers). The trust ensured that all outliers were seen by a consultant, and each ward had a named consultant to carry out this role on a daily basis.

The service used national guidelines and evidence based practice in providing treatment and developing pathways and audits. Audits were completed on both a local and national basis. There were action plans in place to drive improvement, where needed. However, not all risk assessments had been completed in line with the National Institute for Health and Care Excellence (NICE) guidance. Data provided by the trust showed that not all medical wards had met the trust target in compliance with completing Venous Thromboembolism (VTE) assessments throughout 2015.

Records were completed appropriately and we were able to follow and track patient care and treatment easily. However, not all records were kept in locked trolleys or in a locked room to ensure confidentiality.

Staff received mandatory training on a rolling annual programme. The mandatory training was in areas such as moving and handling, fire safety, conflict resolution and dementia awareness. At the time of our inspection the trust reported 89% of medical services staff had completed their mandatory training. However, mandatory training was not up to date for all doctors across medical wards.

Major incident planning took place, however we found that plans had not cascaded down to staff across medical wards. Incidents were well reported by staff, and they had a system in place to safeguard vulnerable people. Medicines were stored and handled appropriately, and regularly checked to ensure compliance with medicine safety.

The wards we visited were visibly clean, and regular auditing took place to ensure the environment was clean and safe for patients. Infection rates were monitored and displayed on all wards we visited.

Patients spoke positively about their care and treatment. They were treated with dignity and respect. Data for patient satisfaction surveys showed most patients were positive about recommending the department to friends and family. Patients and those close to them were supported with their emotional needs.

There was a focus on discharge planning for patients on all wards we visited. Staff discussed discharges at daily board rounds and bed management meetings. The board rounds provided staff with an overview of the care and treatment for each patient and arrangements required to safely discharge a patient. Once patients were discharged, discharge summaries were provided to patients and sent to their general practitioner.

The senior team were visible and accessible and well known to the staff. Staff felt the managers were approachable and supportive.

Urgent and emergency services (A&E)

Requires improvement

Updated 30 June 2016

We have given Urgent and Emergency care services at Wythenshawe Hospital an overall rating of requires improvement.

There was a culture of reporting and sharing learning openly and honestly. The department was visibly clean and tidy in all but two rooms. Cleaning staff were present on a daily basis and the trust monitored cleanliness and infection prevention and control.

The ED infrastructure was fit for purpose and staff thought innovatively to ensure space was used.

Medicines were organised and within expiry date with appropriate checks in place to ensure proper use.

Records were stored securely and contained comprehensive details about patients.

The trust had a central safeguarding team and safeguarding link nurses with specialist knowledge worked in the ED. However, not enough staff were up to date with safeguarding training and compliance with other mandatory training was also low in most staff.

Staff managed patient risk using a rapid assessment and treatment model and a triage system. Some treatments were instigated during initial assessment.

Staffing was adequate and vacancies were handled through recruitment and agency or locum staff. However, trust records showed reliance on locums to fill 28% of medical shifts. There were four vacancies in paediatric nurse staffing but recruitment was in progress.

Major incident equipment was fit for purpose and regularly checked. Equipment was stored in an organised way, within expiry date. Checklists helped ensure equipment was available in treatment areas. However, there was no standardised process to confirm missing equipment had been replaced.

Staff used national and local guidelines and pathways to provide care. Food and refreshment was available but not always offered to patients and visitors. Local and national audits were undertaken. Patients were assessed for pain and treatment was provided when appropriate.

New staff followed an induction process. Appraisal rates were considerably lower than the trust target of 85%.

Staff from different disciplines worked together to provide services for patients. We saw evidence that patient consent was obtained. Mental health staff provided assessments and staff understood the principles of the Mental Health Act 2005.

Although the main ED was open 24 hours a day seven days a week, 365 days a year, not all services operated at evenings or weekends.

Staff were friendly, helpful and respectful, introducing themselves to patients who said they felt informed about their care.

There were systems in place to identify patients who had passed away provide specialist support for bereaved relatives or loved ones.

Language interpretation, sign language and multi faith rooms were available. Link nurses provided specialist knowledge in areas such as dementia, alcohol misuse and safeguarding. Information leaflets were available for patients.

Access and flow remained a problem. The ED had not met the target to see, treat, admit or discharge patients within four hours at all in the last 12 months. Initiatives were in place to try to address this.

We saw evidence that formal complaints were investigated and action taken to resolve them and limit recurrence.

There was a strategy in place for the future and staff were aware of plans to expand the ED over the next three years.

Governance, risk and quality was measured and recorded appropriately, and discussed on a monthly basis in formal meetings. The department had a risk register with risk ratings, actions to mitigate risk, and review dates.

Staff felt well supported by leaders and described a positive team culture with good staff engagement. Staff thought innovatively about improving access and flow and the department itself through accreditation schemes.

Surgery

Requires improvement

Updated 30 June 2016

Staffing levels across surgical services were good, but there was one ward where there were periods of understaffing, which were not always able to be addressed quickly. The trust had previously recognised that staffing levels on two wards were too low to be safe at full capacity. The low levels of staffing had been observed to have an impact on patient care, in that these wards had reported high numbers of incidents, one for falls and the second for pressure ulcers.

In response to the difficulties on these wards trust management had taken appropriate action. This situation had detrimental impact on capacity within surgical beds, which further aggravated trust wide capacity issues and contributed to the high numbers of cancelled operations and failure to meet referral to treatment times.

From December 2015 these wards received substantial extra support and development, which was reflected in the improvements that we found on inspection. We noted that the ward where the incidence of falls had previously been high, had witnessed a reduction in falls, as a result of the measures that had been put in place. Although the second ward had not witnessed a reduction in pressure ulcers, morale had improved and ward based training sessions were being delivered by clinical leaders. However, when we visited this ward on three occasions, there were low staffing numbers for the dependency of the patients, the ward was chaotic, ward equipment was in front of emergency equipment and call bells were being left unanswered for significant periods of time.

There was a positive culture of incident reporting, with staff understanding the value of reporting incidents in improving patient safety. There was a low incidence of infection on all wards across surgical services. Apart from the two wards mentioned, all wards had safe staffing levels with a skill mix deemed appropriate for patient acuity and dependency levels. Medical records were fully completed and medicines were managed safely.

Surgical services provided effective services to patients. It provided services in line with national guidelines and implemented local policies based on national guidelines. Patient’s pain was assessed both pre-operatively and when they arrived on the ward. This pain score was documented and pain relief was administered in a timely fashion. If ward staff required more support when dealing with a patient’s pain, they were able to access the trust pain team. There were good relationships between the pain team and surgical wards, with the pain team visiting some wards on a daily basis.

We observed that surgical services were caring towards patients, interacting with patients in a kind and respectful way. We were able to speak to a number of patients and relatives who stated that all staff were caring and involved them in discussions and decisions about their care.

There were some challenges with access and flow through surgical services; however services were responsive to individual needs of patients. We observed numerous examples where staff adapted services to the needs of patients, including delivering medication through sign language to a deaf patient. The service had considered the changing needs of its population and had trained staff to be ward leaders in care for people with dementia.

The management of surgical services was focused on patient safety and ensuring high standards of care and treatment were provided to patients. Managers and clinical leaders were aware of the issues facing services, such as the ward staffing difficulties and the problems with access and flow through surgical services. They had addressed these problems and developed plans to reduce them. However, at the time of inspection the problems were still evident and impacting on patient care. Managers were not fully aware, however, of the reasons why care had not improved on a ward with difficulties. They had not fully identified the extent to which difficulties with clinical leadership continued to impact on patient care and limit the improvement in care.

Staff morale across surgical services was, in most cases, very high across all professional groups.  Directorate medical directors were focused on new Manchester wide initiatives. Trust management was visible and staff spoke very highly of senior nursing leaders, believing them to be approachable and interested in ward staff.

Intensive/critical care

Good

Updated 30 June 2016

We gave the critical care services at Wythenshawe hospital an overall rating of good. However, we found further improvements were needed in relation to how the service responded to patient needs.

This was because there was insufficient capacity within the critical care services which meant patients were not always admitted promptly to receive the right level of care. The high bed occupancy levels in the critical care services meant operations were cancelled due to the lack of available critical care beds.

As part of the trust’s escalation policy, patients were transferred to the main ‘theatres recovery area when there were no critical care beds available. There had been 59 occurrences of patients being nursed overnight in theatre recovery from April 2015 to October 2015. Patients kept overnight in recovery were assessed by critical care consultants. However, they were cared for by recovery nurses that had not completed all the relevant competencies to treat critically ill patients. There were plans in place to provide training for recovery staff by the end of March 2016.

Patients were not always discharged from critical care in a timely manner due a lack of available ward beds and capacity constraints across the trust. ICNARC data up to September 2015 showed the number of reported delayed discharges (within and greater than four hours) was worse than other comparable units nationally. The data showed the delayed discharges were consistently 10% to 20% above the average since January 2013.

The critical care services had implemented a new patient flow policy in December 2015 to improve access to critical care and reduce delayed discharges. There was also a plan to open a two-bedded long term ventilation and weaning unit by July 2016 that was expected to free up capacity and improve patient access to the adult intensive care unit (AICU).

Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises and were supported with the right equipment. There were systems in place to manage resource and capacity risks and to manage patients whose condition was deteriorating.

Patients were supported by trained, competent staff. The staffing levels and skills mix was sufficient to meet patients’ needs and staff assessed and responded to patient’s risks. Patients and their relatives spoke positively about the care and treatment provided. They were treated with dignity, empathy and compassion and supported with their emotional and spiritual needs.

The services provided care and treatment that followed national clinical guidelines and performed in line with expected levels for most performance measures in the Intensive Care National Audit and Research Centre (ICNARC) audit. There was effective teamwork and clearly visible leadership within the critical care services and staff were positive about the culture and level of support they received. Key risks to the services, audit findings and quality and performance was monitored though routine departmental and clinical governance meetings.

Services for children & young people

Good

Updated 30 June 2016

Overall we rated children’s and young people’s service as good.

Staff were competent in their roles. Mandatory training, including safeguarding, was above the trust targets.

Multidisciplinary and departmental meetings were held amongst all areas of the service. Meetings were regular and were used to explore ideas to improve the patient pathway. They were well attended by senior clinicians and ward managers, safeguarding and other teams. The service was proud of their togetherness and gave several examples where service had improved following these meetings. For example to ensure there were enough beds for patients who presented at the paediatric emergency department (PED), the paediatric day case unit offered staffing support to the paediatric assessment and observation unit. This improved the access and flow pressures in the PED.

The local leaders on the ward and units were visible and managers were actively involved in the day to day running of the paediatric areas. However we noted that managers undertook clinical duties to increase staffing numbers which consequently meant they had limited time for managerial duties. Staff were motivated in their roles and worked well together to deliver a quality and efficient service. There was a strong focus on delivering safe patient care and managers supported staff to develop their skills. However, staff were not always able to attend workshops or training sessions because of operational pressures and time was limited. The service lacked direction and support from the executive board level; this was evident from the staffing provisions.

The neonatal unit did not always meet standards of staffing recommended by the British Association of Perinatal Medicine (BAPM). Nurse staffing levels on starlight ward did not reflect Royal College of Nursing (RCN) standards; an acuity tool on the starlight ward was not in use at the time of the inspection. We raised concerns with senior leaders, highlighting the need for more staffing provisions in both areas. Staff undertook extra shifts on a weekly basis to make the ward safe but this was not sustainable. It was evident that staff were overworked but many staff felt obligated to pick up more than three extra shifts to make sure the ward ran efficiently so that care was delivered safely. The percentage of consultants (26%) working in paediatrics was worse than the England average (35%). Staff felt there was a lack of senior leadership. Although staff were aware of how to escalate their concerns to their manager or matron at ward level, there was little evidence of direction or support to mitigate risks from the executive board because staffing levels had not been addressed.

Documentation on the paediatric ward was poor. We also raised concerns about the transfer of nursing notes from the nurse led book. This book contained patient information and was used by nursing staff as a daily task list. After cross referencing the book with 16 medical and nursing case notes we found 10 patients notes did not contain information that had been written in the nurse-led book. These concerns were escalated to the executive team on the unannounced inspection The nurse led book also raised serious concerns about data protection; If the nurse led book was requested by a parent this would also contain information about other children. This information was not coded and was not redacted once the book was completed.

Transition arrangements for children between 16 and 18 years were found to be rigid with all children over 16 years admitted to the adult services. This included children and young people admitted with mental health or self-harm concerns and also included young people with learning disabilities. The adult service used the integrated care pathway and escalated risk pathway however this pathway had been designed for adult patients.

End of life care

Good

Updated 30 June 2016

Overall we rated end of life care as good because:

The trust responded to practice changes in relation to replacing the Liverpool Care Pathway and in June 2014 introduced the ‘Individual plan of care for people who are dying’ (IPoC). This was based on ‘Five priorities for end of life care’ developed by the Leadership Alliance for the Care of Dying People.

The specialist palliative care team and other services involved in end of life care were caring and took steps to maintain patient dignity and comfort. Processes were in place to provide emotional and practical support to the patient and their family. There was provision for people with communication difficulties, this included an interpreter service.

Multiagency working was well established and processes were in place to enable patients and relatives to be involved in advance care planning. Preferences were observed when possible and cultural and religious needs were taken into account.

The trust provided a seven day a week specialist palliative care service in the hospital. Due to staff shortages and uncertain funding arrangements, the community team had been reduced to five days. The trust provided an out of hours on-call service to the hospital staff and district nurses and GPs.

Processes were in place to ensure senior doctors were able to assess the patient’s needs using the five priorities. Medications to control the symptoms of end of life (anticipatory medication) were prescribed in good time.

Areas for improvement were identified in relation to prescribing medication and assessing pain. The medication administration record did not differentiate between whether medication was been given for pain control or to relieve shortness of breath. This meant that medication record could not be interpreted without referring to the medical or nursing notes. Also, although an initial pain assessment was completed and medication prescribed, staff did not routinely score the level of pain described by the patient using the tool provided. This meant the effectiveness of pain control was not monitored in line with best practice guidance.

The trust participated in a number of local, regional and national audits and re-audits to identify areas of effective practice and improvement. They were proactive in developing and implementing action plans to improve adherence to best practice guidance or develop new ways of working. This included monitoring whether end of life care was consistently delivered against the ‘five priorities of the dying person’, preferred place of death and access to palliative care services. Audits, plans and checks could be improved if targets dates for the completion of projects were always identified.

Do not attempt cardio-pulmonary resuscitation documentation was consistently completed to a good standard. Staff understood the systems in place for escalating safeguarding concerns and demonstrated a good understanding of the Mental Capacity Act.

Nurse managers and senior medical staff who led services involved in end of life care in the trust were accessible to staff, patients and their relatives. The trust’s 2010 -2020 strategy for end of life care was in draft stage and should be expedited, however, strategic work to improve services were ongoing.

The trust had introduced customer satisfaction processes and acted on information provided by patients, relatives and staff. The trust should consider a staff survey aimed at palliative care and end of life staff.

We visited 13 wards, the multi-faith centre, the chaplaincy service, the chapel of rest, the mortuary and the bereavement office. We spoke with nine patients and relatives. We also talked with 52 members of staff from all departments at the trust involved with providing with end of life and palliative care services. We reviewed the trust’s performance data.

Outpatients

Requires improvement

Updated 30 June 2016

The trust experienced a shortage of nurses and radiographers within the diagnostic and imaging department. Ageing equipment within radiology had begun to impact on service delivery. Diagnostic waiting times were worse than the England average from August 2014 onwards, with performance particularly bad during the second half of 2014. Between June 2015 and September 2015, the proportion of radiological investigations reported on within 10 days ranged from 68% to 75.5%. Some patients with increased body mass index (BMI) could not receive the gold standard diagnostic procedures for breast problems due to doorways not being wide enough in the Nightingale Centre.