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Inspection Summary


Overall summary & rating

Good

Updated 9 March 2018

A summary of our findings about this location appears in the overall summary

Inspection areas

Safe

Good

Updated 9 March 2018

Effective

Good

Updated 9 March 2018

Caring

Good

Updated 9 March 2018

Responsive

Good

Updated 9 March 2018

Well-led

Good

Updated 9 March 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 22 June 2016

We found the services of the outpatients and diagnostic imaging to be good overall. Patients had clear access to the clinics and radiology, though car parking was an issue. Areas were visibly clean and waiting times for appointments were short. The departments had sufficient staff and where shortfalls existed there were plans in place to ensure continuous service. There was some weekend clinics and acute radiology services was open 24 hours a day. The outpatient waiting area was dated but the new cancer centre, opened in January 2015, was bright and spacious in comparison.

Staff at Royal Albert Edward Infirmary told us they were proud of where they worked and would recommend it as a workplace and a place to treat their family. Staff training was up to date and the trust encouraged learning. Incidents and errors were treated as a learning opportunity to keep patients safe in the future. Patients told us that staff were caring and compassionate and they were given sufficient information about their treatment.

The management were visible and approachable to staff. Audits to assess the departments were continuous and innovation and change was promoted. Staff felt supported by the managers.

Maternity and gynaecology

Requires improvement

Updated 9 March 2018

We previously inspected maternity jointly with gynaecology and rated the services as requires improvement. During this inspection we only inspected maternity services. We rated it as requires improvement because:

  • The trust had put right many of the issues that we had identified in the December 2015 inspection in maternity. However, there were some issues, which had not been resolved, and other new issues identified since the last inspection.
  • While staff recognised and reported incidents well, shared learning to reduce recurrence was limited.
  • Safety systems, processes and standard operating procedures were not always reliable or appropriate to keep women and babies safe. Staff did not always follow policies and national guidance.
  • The service did not always have adequate medical and midwifery staffing levels to keep women and babies safe from avoidable harm and abuse and to provide the right care and treatment. Staff did not continuously assess, monitor or manage risks to women who used the service. Opportunities to prevent or minimise harm were missed.
  • There was no established pastoral care system in place following bereavement. The trust did not employ a bereavement midwife.
  • Not all staff was aware of the maternity vision and strategy plan or the maternity service development plan.
  • There was limited evidence of public engagement.
  • Governance processes had not been used effectively to identify and mitigate risks, improve safety and performance and prevent reoccurrence of adverse incidents. There was no evidence of strong medical leadership to improve productivity and clinical practice.

However:

  • There was an established mandatory training programme for midwives.
  • Staff identified potential safeguarding risks, involved relevant professionals and had systems in place to manage it.
  • Performance and patient outcomes on the maternity dashboard were good.
  • Stillbirth rates were on a downward trend.
  • There was an established training and competency programme for midwives who worked in the maternity theatres.
  • There was active and appropriate engagement in safeguarding procedures and effective work with other relevant organisations.
  • The culture among staff was good.
  • Patients were positive about their care.

 

Medical care (including older people’s care)

Good

Updated 9 March 2018

Our overall rating of this service stayed the same. We rated it as good because:

  • Staff knew what incidents to report and how to report them. Managers investigated incidents and shared lessons learned. They identified themes and monitored near misses.
  • The service had systems that managed prescribing, administering, recording and storage of medicines well.
  • The wards were clean and equipment was well maintained. Staff followed infection control policies that managers monitored to improve practice.
  • Compliance with mandatory training and the number of staff receiving annual appraisals had improved since the last inspection.
  • Doctors, nurses and other health professionals worked together to support each other and provide good care.
  • Staff treated patients with compassion, dignity and respect. Patients and their relatives could also talk to managers who they saw on the wards.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness and managers monitored the effectiveness of the services through regular audits.
  • Staff understood how to protect patients from abuse and how to assess patients’ capacity to make decisions about their care. Staff had training on safeguarding, the Mental Capacity Act, and Deprivation of Liberty Safeguards.
  • Staff and managers were clear about the challenges the service faced. They explain the risks to the department and the plans to deal with them.

However:

  • Nurse staffing was challenging across medical services and there were occasions when shifts were not covered as planned. There were significant improvements in recent months and the service had plans to address the issue, mitigate risk, and monitor service provision to maintain safe care on the wards.
  • The service did not care for all patients in the most appropriate bed and when the service needed to move patients between beds it did not always do this during the daytime.
  • Divisional risk registers did not always demonstrate that actions were taken to mitigate and manage all risks effectively.

Urgent and emergency services (A&E)

Good

Updated 9 March 2018

Our overall rating of this service stayed the same. We rated it as good because:

  • The service managed patient safety incidents well, recognising and reporting them and sharing learning to limit recurrence.
  • The service controlled infection risk and kept appropriate records of patients’ care and treatment.
  • The service prescribed, gave and recorded and stored medicines well and staff had access to an electronic records system that they could update.
  • Staff understood how to protect patients from abuse and received appropriate training. Training rates had improved since our last inspection.
  • The service provided mandatory training to all staff and made sure staff completed it and were competent in their roles. Staff had the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service provided care and treatment based on national guidance and monitored the effectiveness of care and treatment and used findings to make improvements.
  • Staff gave enough food and drink to meet patient needs and worked together as a team to benefit patients.
  • Staff cared for patients compassionately. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment and provided emotional support to patients to minimise distress.
  • The service planned and provided services in a way that met the needs of local people and generally took account of patients’ individual needs.
  • People could access the service when needed. Whilst waiting times were not always in line with national targets, staff used a number of initiatives to try to improve them and maintain patient flow.
  • Staff treated concerns and complaints seriously. They investigated them and learned and shared lessons from the results.
  • The service had managers at all levels with the right skills and abilities to run the service. They had a vision for achieving goals and workable plans were being put into action to achieve them.
  • Managers promoted a positive culture that supported and valued staff and engaged effectively with staff and patients. They collaborated with partner organisations effectively.
  • The service had effective systems for identifying risks, and taking action to reduce them and showed commitment to improving services

However:

  • Staffing levels in the paediatric emergency care centre were not always adequate to care for children overnight.
  • Despite keeping areas and the majority of equipment clean, staff did not keep all waste, equipment and cleaning products secure from the public. Completed cleaning was not recorded in an organised way.
  • Whilst the majority of individual needs were met, those relating to vulnerable patients requiring discharge or transfer and waiting times were not always managed effectively.
  • Despite managing competencies well, we identified that staff training in the Mental Capacity Act and Deprivation of Liberty Safeguards was minimal. We also identified that staff caring for a mental health patient had not followed trust policy relating to completing a formal capacity assessment.

Surgery

Good

Updated 22 June 2016

Overall, we found that the Royal Albert Edward Infirmary delivered ‘Good’ surgical services.

Staff were committed and proud of the services they provided. Staffing levels were sufficient and a safer nursing care staffing tool was utilised to ensure staffing levels were adequate. Medical staff rotas were in place and locum agency staff filled any gaps when the service was short staffed. Staff morale was good and staff felt well supported.

Incidents were reported and lessons learnt shared amongst staff. Staff knew how to access the incident reporting system and could tell us about incidents they had reported. There were low incidents of pressure ulcers and infections. Risk assessments were completed and staff implemented measures to reduce risks.

The environment was clean and tidy and staff had access to the equipment they required to do their jobs. Medicines were managed safely and stored securely.

Referral and discharges worked well and staff shared relevant information. Services worked in coordination and patients were appropriately referred to specialist services. Staff treated patients with respect and dignity, offered support and included them in care planning. Patients received a caring service and staff discussed treatment plans with patients to ensure a person-centred approach.

The trust 18 week referral to treatment times were similar to or above the national average of 90% for all surgical specialities except general and oral surgery. WWL is in the top 10% nationally for RTT performance as at October 2015, ranking 5th out of 139 Acute Trusts.

Risk registers were in place and discussed at team meetings. Staff were aware of the trust’s values and vison. Staff felt well-supported by managers and colleagues.

Intensive/critical care

Good

Updated 22 June 2016

We rated the critical care services at the hospital as good. This was because patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises. The staffing levels and skill mix was sufficient to meet patients’ needs. Patients were supported with the right equipment. Patients received care and treatment by trained multidisciplinary staff that worked well as a team.

Medicines were stored and administered appropriately. However, fridge temperatures were not always maintained below 8ºC. Staff minimised the risk to patients by taking additional steps such as reducing the expiry date of medicines stored in the fridges.

The services provided care and treatment that followed national clinical guidelines and staff used care pathways effectively. The services performed in line with expected levels for all performance measures in the Intensive Care National Audit and Research Centre (ICNARC) 2013/14 audit. This meant the majority of patients had a positive outcome following their care and treatment.

There was sufficient capacity to ensure patients could be admitted promptly and receive the right level of care. Bed occupancy levels were consistently lower than the England average. The number of out-of-hours discharges, delayed discharges and patients transferred out for non-clinical reasons were within expected levels when compared to other critical care units nationally.

The relatives of patients spoke positively about the care and treatment provided. Patients were treated with dignity, empathy and compassion. Staff involved patients or their relatives in their care and supported them with their emotional and spiritual needs.

There were systems in place to support vulnerable patients. Complaints about the service were shared with staff to aid learning. There was effective teamwork and clearly visible leadership within the department. Staff were positive about the culture within the critical care services and the level of support they received from their managers.

Services for children & young people

Good

Updated 9 March 2018

Our overall rating of this service improved. We rated it as good because:

  • Local systems and processes reflected a culture of improvement. For example, reporting incidents, regular audits and reviews, introduction of local champions and practice development nurses to have oversight of, and improved staff competencies by supported learning.
  • There had been improvements in compliance with mandatory training and the introduction of role specific compulsory training.
  • The service were committed to reducing the recruitment of agency staff and instead used bank staff.
  • Staff demonstrated compassionate care. Patients’ and families religious, emotional, and social needs were understood and the resources provided.
  • The leadership team demonstrated a commitment to delivering good quality care. They had an understanding of priorities in their service; the challenges they might present and the changing needs of those who required the service.
  • There was a culture of good governance, service improvement and staff development. There were a number of methods used by the leadership team to ensure they audited and reviewed the quality of their work. There were systems in place to help maintain standards in line with national guidance. The leadership team were supported by the trust to ensure they continued to grow and develop as a service.

End of life care

Outstanding

Updated 22 June 2016

We found that there were good EOL services across all five domains of Safe, Effective, Caring, Responsive and Well Led.

Incident reporting systems were in place and actions were followed up at ward level via handover. There had been no recent serious incidents related to EOL care. Anticipatory EOL care medication was prescribed appropriately and training for the use of syringe drivers was included in mandatory training for which the SPC team were 100% compliant. EOL services were adequately staffed and as well as the SPC team which was clinically led by a consultant in palliative medicine, there was a bereavement specialist nurse, a gold standards framework (GSF) facilitator and two EOL champions on each ward.

There was evidence of the service delivering treatment and care in line with best practice, including the individual plan of care (IPOC) document which facilitated support for the dying person in the last days and hours of life. The service was starting to implement the gold standard framework (GSF) and had appointed a facilitator to introduce and embed this in the two pilot wards. We saw that the service had made changes to their practice to address some of the targets not met in the last National Care of the Dying Audit of Hospitals (NCDAH), May 2014 and there was evidence that some actions were in place as a result of other clinical audits however there were not always action plans in place which met the criteria for being specific, measurable, achievable, realistic and timely (SMART). This meant there was a potential risk that some recommendations or findings from audits may not be translated into actions in a timely manner or may be missed altogether.

We saw evidence that pain relief and nutrition and hydration needs for patients were being met. The SPC team provided a seven day service and worked well, across all the hospitals, with other teams and disciplines.

EOL care services were provided by compassionate, caring staff who were sensitive to the needs of seriously ill patients. The service was delivered by staff who were committed to providing a good service and there was good clinical leadership from a consultant in palliative medicine. There was a coordinated approach across the Wigan borough to design EOL services to meet the needs of the local population. There were systems in place to prioritise EOL patients for side rooms at RAEI and this was working well. Facilities and systems were in place to minimise stress for families staying with their EOL relatives and to allow them to spend as much time as they wished with them in their last days and hours. This included the use of the swan logo which identified EOL patients and their families, enabling staff to treat them accordingly.

The visibility of senior management was good and staff felt well supported and there was an open door policy by senior staff.

Areas for improvement included completion of uDNACPR forms which were inconsistent in their quality. An action plan should be developed to address the shortcomings identified in the trust’s uDNACPR audit.