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Royal Albert Edward Infirmary Requires improvement

We are carrying out checks at Royal Albert Edward Infirmary using our new way of inspecting services. We will publish a report when our check is complete.

Reports


Inspection carried out on 17 March 2017

During an inspection to make sure that the improvements required had been made

The Royal Albert Edward Infirmary is a large district general hospital operated by Wrightington, Wigan and Leigh NHS Foundation Trust. It provides a full range of hospital services including emergency care, critical care, general medicine (including elderly care), surgery, neonatal care, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services. The hospital has 513 beds.

Urgent and emergency services and children and young people’s services at Royal Albert Edward Infirmary were previously inspected in December 2015. Urgent and emergency services were rated as ‘good’ and children and young people’s services were rated as ‘requires improvement’.

In March 2017, we carried out an unannounced inspection of these services to review specific areas of care including the assessment and observation of patients, record keeping, pathways of care for discharging or transferring patients, staff training and staffing levels.

The inspection was in response to concerns that were raised about the safety of services provided to patients. The inspection therefore focused solely on the safety of services provided. We inspected the hospital during the evening/night of 17 March 2017, visiting the following areas:

  • Paediatric Emergency Care Centre (PECC)
  • Emergency Care Centre (ECC)
  • Rainbow Ward

We found that these services required improvement for safety. This was because the systems and processes for recognising risks and escalating the deteriorating patient were not always adhered to, records were not always completed correctly and compliance levels in some areas of training, such as safeguarding level three, were lower than the trust target.

Our key findings were as follows:

  • Records were not always completed fully by medical and nursing staff. This meant there was limited evidence of the care provided to patients.

  • Despite tools being available to help staff manage risks to patients, they were not always used effectively. For example, in some records we reviewed we saw no evidence of clinical observations, early warning scores and risk assessments. We also had concerns that some of the guidance relating to managing risk was unclear. For example, one piece of guidance instructed staff to complete ‘routine’ observations, without clarifying the specific frequency.

  • Mandatory training figures for staff did not always reach the trust target of 95%. Training for safeguarding was particularly low. This posed a risk that staff may not have the necessary training to enable them to care for patients appropriately.

  • Dispensers storing sanitising gel were empty in the main reception area in the emergency care centre. This limited people’s ability to clean their hands effectively prior to entering the department.

  • A room in the emergency care centre storing major incident and chemical decontamination equipment was also used occasionally to take blood samples from patients. The room was a less than ideal environment with large items of equipment next to the trolley where patients sat to provide their samples.

  • Duty of candour was not fully documented in the investigation report following the never event on Rainbow ward.

  • Appropriate action was not always taken following completion of the Paediatric Early Warning Score (PEWS) on Rainbow ward.

    However:

  • Following our inspection in December 2015, the trust had improved the levels of training for nurses on Rainbow ward, with higher compliance in advanced paediatric life support and tracheostomy care.

  • Staffing levels on Rainbow ward were also improved, with greater numbers of staff available to care for children at all times.

  • Staff in the Emergency Care Centre were able to explain their actions during major incidents or incidents involving hazardous substances.

In areas of poor practice the trust needs to make improvements.

Importantly, the trust must:

  • Ensure staff complete mandatory safeguarding children training appropriate to their role.
  • Ensure staff complete other mandatory training to maintain compliance in line with the trust target.
  • Ensure that tools to manage risk are used and recorded such as completing risk assessments and observations and taking appropriate action when triggering Paediatric Early Warning Scores (PEWS).
  • Ensure that patient records are accurate and complete.

In addition the trust should:

In relation to children and young people services:

  • Ensure duty of candour is documented following a notifiable safety incident.
  • Ensure cleaning schedules are consistently completed in all areas.
  • Ensure the expiry date is legible on all controlled drugs.
  • Ensure the medicine fridge thermometer is reset in line with trust policy and action taken is documented when the fridge temperature deviates from the acceptable range.
  • Ensure the refrigerator in the milk room is available and fit for use.
  • Ensure current guidelines for the management of paediatric sepsis are available for staff.

In relation to urgent and emergency services:

  • Ensure trust guidance is consistent throughout all departments in relation to the use of early warning scores, clinical observations and general monitoring of patients, and that where required, categories and frequency of monitoring is stipulated to ensure clarity.
  • Ensure that all staff use the same guidance relating to the frequency of observations
  • Ensure that sanitising gel is available in all dispensers
  • Review the suitability of the room used to store major incident equipment in relation to taking blood samples from patients
  • The trust should review the entrance and exit door to the paediatric emergency care centre with a view to ensuring the risk of children or young people exiting the department is as low as practicable.
  • Consider amending the checklists used on resuscitation trolleys to ensure any action to replace missing items can be documented to avoid potential confusion.
  • Consider introducing checklists to record that defibrillators have been checked rather than relying on printed strips stored in no particular order.
  • Obtain assurance and ensure that staff involved in assessing patients are aware of, or appropriately prompted to consider female genital mutilation
  • Ensure that guidance about conditions requiring senior medical review covers occasions when consultants are not on site and available only on an on call basis.
  • Ensure that the care pathway for caring for patients with a blood borne virus is up to date and that the latest version is displayed on the relevant noticeboard in the emergency care centre.
  • Only store equipment in appropriate packaging and remove equipment that is not stored in this way.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection carried out on 8-11 December 2015

During a routine inspection

The Royal Albert Edward Infirmary is a large district general hospital operated by Wrightington, Wigan and Leigh NHS Foundation Trust. It provides a full range of hospital services including emergency care, critical care, general medicine (including elderly care), surgery, neonatal care, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services. The hospital has 513 beds.

Urgent and emergency services and children and young people’s services at Royal Albert Edward Infirmary were previously inspected in December 2015. Urgent and emergency services were rated as ‘good’ and children and young people’s services were rated as ‘requires improvement’.

In March 2017, we carried out an unannounced inspection of these services to review specific areas of care including the assessment and observation of patients, record keeping, pathways of care for discharging or transferring patients, staff training and staffing levels.

The inspection was in response to concerns that were raised about the safety of services provided to patients. The inspection therefore focused solely on the safety of services provided. We inspected the hospital during the evening/night of 17 March 2017, visiting the following areas:

  • Paediatric Emergency Care Centre (PECC)
  • Emergency Care Centre (ECC)
  • Rainbow Ward

We found that these services required improvement for safety. This was because the systems and processes for recognising risks and escalating the deteriorating patient were not always adhered to, records were not always completed correctly and compliance levels in some areas of training, such as safeguarding level three, were lower than the trust target.

Our key findings were as follows:

  • Records were not always completed fully by medical and nursing staff. This meant there was limited evidence of the care provided to patients.

  • Despite tools being available to help staff manage risks to patients, they were not always used effectively. For example, in some records we reviewed we saw no evidence of clinical observations, early warning scores and risk assessments. We also had concerns that some of the guidance relating to managing risk was unclear. For example, one piece of guidance instructed staff to complete ‘routine’ observations, without clarifying the specific frequency.

  • Mandatory training figures for staff did not always reach the trust target of 95%. Training for safeguarding was particularly low. This posed a risk that staff may not have the necessary training to enable them to care for patients appropriately.

  • Dispensers storing sanitising gel were empty in the main reception area in the emergency care centre. This limited people’s ability to clean their hands effectively prior to entering the department.

  • A room in the emergency care centre storing major incident and chemical decontamination equipment was also used occasionally to take blood samples from patients. The room was a less than ideal environment with large items of equipment next to the trolley where patients sat to provide their samples.

  • Duty of candour was not fully documented in the investigation report following the never event on Rainbow ward.

  • Appropriate action was not always taken following completion of the Paediatric Early Warning Score (PEWS) on Rainbow ward.

    However:

  • Following our inspection in December 2015, the trust had improved the levels of training for nurses on Rainbow ward, with higher compliance in advanced paediatric life support and tracheostomy care.

  • Staffing levels on Rainbow ward were also improved, with greater numbers of staff available to care for children at all times.

  • Staff in the Emergency Care Centre were able to explain their actions during major incidents or incidents involving hazardous substances.

In areas of poor practice the trust needs to make improvements.

Importantly, the trust must:

  • Ensure staff complete mandatory safeguarding children training appropriate to their role.
  • Ensure staff complete other mandatory training to maintain compliance in line with the trust target.
  • Ensure that tools to manage risk are used and recorded such as completing risk assessments and observations and taking appropriate action when triggering Paediatric Early Warning Scores (PEWS).
  • Ensure that patient records are accurate and complete.

In addition the trust should:

In relation to children and young people services:

  • Ensure duty of candour is documented following a notifiable safety incident.
  • Ensure cleaning schedules are consistently completed in all areas.
  • Ensure the expiry date is legible on all controlled drugs.
  • Ensure the medicine fridge thermometer is reset in line with trust policy and action taken is documented when the fridge temperature deviates from the acceptable range.
  • Ensure the refrigerator in the milk room is available and fit for use.
  • Ensure current guidelines for the management of paediatric sepsis are available for staff.

In relation to urgent and emergency services:

  • Ensure trust guidance is consistent throughout all departments in relation to the use of early warning scores, clinical observations and general monitoring of patients, and that where required, categories and frequency of monitoring is stipulated to ensure clarity.
  • Ensure that all staff use the same guidance relating to the frequency of observations
  • Ensure that sanitising gel is available in all dispensers
  • Review the suitability of the room used to store major incident equipment in relation to taking blood samples from patients
  • The trust should review the entrance and exit door to the paediatric emergency care centre with a view to ensuring the risk of children or young people exiting the department is as low as practicable.
  • Consider amending the checklists used on resuscitation trolleys to ensure any action to replace missing items can be documented to avoid potential confusion.
  • Consider introducing checklists to record that defibrillators have been checked rather than relying on printed strips stored in no particular order.
  • Obtain assurance and ensure that staff involved in assessing patients are aware of, or appropriately prompted to consider female genital mutilation
  • Ensure that guidance about conditions requiring senior medical review covers occasions when consultants are not on site and available only on an on call basis.
  • Ensure that the care pathway for caring for patients with a blood borne virus is up to date and that the latest version is displayed on the relevant noticeboard in the emergency care centre.
  • Only store equipment in appropriate packaging and remove equipment that is not stored in this way.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection carried out on 18 July 2013

During an inspection to make sure that the improvements required had been made

We inspected the hospital in November 2012 and again in April 2013. At both of these inspections we found that the hospital was not meeting the standards required for the management of medicines. We issued a Warning Notice after our inspection April 2013 and asked the hospital to make improvements. We issue Warning Notices to a registered person [in NHS Trusts this person is the Chief Executive Officer(CEO)] where the quality of the care they are responsible for falls below what is legally required.

After our inspection in April 2013, the provider (the hospital senior managers) wrote to us and told us about the changes that had made and those that they were planning to make. When we visited in July 2013 we found that that many improvements had been made. Patients told that they had no concerns about their medicines. One patient told us “You can see the nurses checking your medicines before they give them to you. This makes me feel safe.” We found that the hospital was now meeting the standards for the management of medicines.

We looked at the systems in place for checking that medicines were managed safely within the hospital. This is sometimes referred to as a quality assurance system. We found that significant improvements had been made and that the hospital was now meeting this standard too.

Inspection carried out on 11 April 2013

During a routine inspection

This was a follow up inspection to the one that we carried in November 2012. At that inspection we found that there were concerns about the timeliness with which patients received fluids, the level of privacy and dignity and arrangements in place regarding the management of medicines for patients administering their own medication whilst in hospital. We were also concerned as there were not always plans in place to achieve full compliance with guidelines issued by the National Institute for Health and Clinical Excellence (NICE).

At this inspection we visited five wards and did not find any concerns about patients’ care. We spoke with nine patients who told us that they were well looked after. Patients’ comments included “Everything is fine. They have kept me informed about what is happening.”; “I had a long wait in A&E but staff were very busy. My experience has been OK” and “There are lovely staff. They have been very good to me.”

Most patients said that there were no issues with their medicines. However when we checked patients’ records we found that patients were not always receiving the medicines that they should. There were systems in place to check that patients had been given the correct medicines at the correct time but the problems identified had not been followed up with actions.

Inspection carried out on 28 November 2012

During an inspection in response to concerns

We visited the hospital because we had concerns about some serious incidents that had happened within the operating theatres at Royal Albert Edward Infirmary (Wigan Infirmary) and also at Wrightington Hospital. These incidents occurred because internationally recommended checklists were not being completely followed on some occasions. We found that systems had improved within the operating theatres where the serious incidents had taken place. However, some theatre staff told us that they did not always get the required level of support from some of the surgeons.

Some patients told us they were very happy with the care that they received and we heard comments such as “The doctors explain everything, nothing is too much trouble." On one ward of the five we visited we heard mixed feedback from patients about the care they received. Two patients told us that they had not received pain relief. We were also concerned about the timeliness with which patients received fluids, the level of privacy and dignity and arrangements in place regarding the management of medicines.

We spoke with 15 staff who all told us that they received sufficient training for their roles and that they were supported in their jobs.

There were systems in place to monitor the quality of care being delivered. However, it is a concern that there were not always plans in place to achieve full compliance with guidelines issued by the National Institute for Health and Clinical Excellence.

Inspection carried out on 22 September 2010

During an inspection to make sure that the improvements required had been made

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.