The Care Quality Commission (CQC) carried out this comprehensive inspection because the Alder Hey Children’s NHS Foundation Trust had been flagged as a potential risk on the CQC’s intelligent monitoring system (which looks at a wide range of data, including patient and staff surveys, hospital performance information, and the views of the public and local partner organisations). Alder Hey Hospital has been inspected three times since its registration with CQC. The most recent inspection took place in December 2013. This was a responsive inspection focusing on the operating theatres as we had been made aware of concerns in this area. The inspection found that trust was not meeting the following essential standards:
- Care and welfare of people who use services
- Supporting workers
- Assessing and monitoring the quality of service provision.
The inspection took place between 20 and 22 May 2014, and an unannounced visit took place between 6am and 11am on Sunday 1 June 2014.
We followed up the outstanding compliance issues as part of this inspection.
Overall, this trust required improvement, although we rated it ‘good’ in terms of having effective and caring services.
Our key findings were as follows:
Nursing staff were caring and compassionate and treated children and young people with dignity and respect.
Staff were highly committed to giving children and young people a high standard of care and treatment. Nurse staffing levels on most wards within the medical division were calculated using a recognised dependency tool. However, some services had nursing vacancies. While the trust was actively recruiting to these vacancies, some areas did not provide the minimum staffing levels required, mainly at night. The trust had a system for escalating staffing shortages; however, requests for additional bank (overtime) or agency staff were not always filled, or were filled with staff that did not have the necessary expertise in a particular specialist area. When possible beds were closed to maintain safe staff to patient ratios, however, this was not always achievable in cases of unplanned absence and meant that there were times when wards were short staffed. This was a particular concern in the medical and surgical wards. The trust had already addressed the shortfall in the accident and emergency (A&E) department by providing an additional nurse for the night shift seven days per week.
The hospital was staffed by highly skilled, competent and well-supervised doctors. Medical staff were universally committed to the care and treatment of children and young people. Consultants were present or accessible 24 hours a day and carried out daily ward rounds. Middle grade and junior doctors were on site 24 hours a day. However, the model of care in the high dependency unit (HDU) meant that there were clinical risks associated with a lack of overall medical leadership, clinical accountability and timely clinical decision making. The trust was aware of the risks associated with the HDU and had developed some solutions for the short and medium term, prior to the planned move to the new hospital. However, we were not assured that the arrangements were always promoting the safety of children and young people on the unit and we requested that immediate remedial action be taken by the trust to mitigate the risks. On the unannounced visit, it was clear that immediate steps had been taken to improve the level of medical support on the HDU and an intensive care consultant had been allocated to the unit for 50% of their working time.
The trust had a well-established mortality review process. The aims were for departments and services to undertake a mortality review within two months of the patient’s death with a further review by the Hospital Mortality Review Group within four months to check the findings. The review did not always occur within the four-month timescale, largely due to clinical workloads. There were minimal variances in the findings. Both reviews identify any elements of the patient journey where harm and/or death was avoidable. Root cause analysis investigations are completed where this can add additional learning and action plans are generated and implemented.
The hospital was clean throughout and there was good practice in the control and prevention of infection.
There had been positive changes made in the neonatal surgical unit (NSU) following an infection outbreak in 2013.
Staff applied good practice guidance, supported by training and dedicated staff for control of infection.
Some infection risks were related to the age and fabric relating to the 100-year-old hospital building. However, the trust was responding well to the challenge and managing the physical environment well until the planned move to a new hospital in 2015.
The hospital infection rates for Clostridium difficile (C.difficile) and MRSA infections were within an acceptable range for a hospital of this size.
Nutrition and hydration
There was a range of specialist support to ensure that children and young people’s nutritional needs were met. Dietary and nutritional requirements were considered as part of the care planning process. Specialist support was available for a range of conditions, including children who had diabetes and coeliac disease.
The oncology unit had a designated chef onsite to support young people’s nutritional needs.
On the NSU a dietician visited and reviewed all babies on a daily basis.
A new initiative on the NSU was ‘Promoting transition to breastfeeding’, a pathway for promoting breastfeeding and the health benefits for babies.
Fluid charts were completed, and recorded inputs and outputs. If babies were having total parenteral nutrition (nutrition administered intravenously) their daily weight was monitored to ensure that their nutritional and hydration needs were met.
Children and young people were complimentary overall about the food provided.
Improvements were required to ensure that food and drink was more readily available in the A&E department. There was a vending machine available for drinks and snacks, with a wider choice of food available in the canteen, however, children and young people (and their parents and carers) were reluctant to leave the department in case they missed their ‘turn’. Staff told us that they would provide a drink and toast to children and young people who had been waiting in the department for a long time if asked.
Nevertheless, there was no formal system to ensure that nutritional and hydration needs were met for children and their families waiting for long periods in the A&E department.
The trust had medicines governance and incident reporting structures. The policies and procedures for medicines handling were robust and the relevant guidelines were followed.
The pharmacy department provided a good service to most of the wards in the hospital but, due to staff shortages, could only provide a partial service to some wards. The staff shortages impacted on the ability of pharmacists to complete medicines reconciliation for each patient within the first 24 hours of their admission (recommended to reduce preventable medication errors).
Nurses and parents said there were no delays in children being discharged home as there was an effective system for ensuring that discharge medication was available in a timely manner. However, we observed that there were often delays with people being attended to by pharmacy staff when they had an outpatient’s prescription to be dispensed.
Pharmacy staff undertook training and competency assessments prior to visiting wards to ensure their practice was safe.
A review of the drug charts on the wards showed that nurses were not following the trust’s policy regarding the safe administration of medicines, which stated that two nurses must prepare and administer medicines to each child.
We found on two wards that nurses were not completing the records about the administration of medicines in line with NMC guidelines because they did not make an immediate record of the medicines administered. We saw that, on one of the wards, all medicines were signed for before any medication was given, and nurses told us this was usual practice.
Medicines were stored on the wards in lockable cupboards and fridges in dedicated clinical rooms. Entry to the rooms was by means of keypads. On a number of wards, we found that the fridges were unlocked. Nurses told us the key codes were not changed regularly, and we observed on one ward that people who were not authorised to have access to the room had access to the key code. This could allow unauthorised access which may lead to drug tampering.
Some medicines were not administered in accordance with safe medicine practice and there were no robust systems to ensure best practice. Interventions by pharmacists to improve patient safety were not reported as incidents and, unless they were deemed to be significant, no notes were made to support learning. We saw examples where had the Pharmacist not intervened then it would have resulted in an error. We saw that the pharmacist did not record the errors in patients’ notes or in any communications with the ward staff or managers or doctors. Nurses told us that no discussions took place about errors that Pharmacists found on the patient’s drug charts and that doctors were not formally informed of the changes made.
There was an incident reporting system in the trust and staff said they understood how and when to make reports. However, information received from the trust, together with our findings showed that incidents were under-reported, limiting the opportunity for learning and reducing the risk of harm.
We spoke with patients and their parents who all told us they were happy with the levels of information they had about their medicines and felt they understood what medicines were prescribed for and how to take them. However, only one parent told us that the side effects of the medication had been explained.
Staff had a good knowledge and understanding of safeguarding procedures and knew how to contact the hospital safeguarding team, should this be necessary.
The electronic system within the hospital identified children and young people with a child protection plan.
Training records indicated that only 61% of staff across all divisions in the trust had received level 1 (the lowest level) safeguarding training or a safeguarding update within the last year. There were initiatives in place to increase the level 1 safeguarding training, including increased use of e-learning and workbooks. This work should continue as a matter of priority so that all staff have received current training in identifying issues of abuse and neglect and are able to escalate their concerns appropriately.
Meeting the needs of young people
Managers and frontline staff were not aware of the Department of Health’s 2011 standard ‘You’re Welcome’ quality criteria for young people friendly health services. We were advised that the You’re Welcome accreditation will be through the Healthy Liverpool Integrated Care Delivery (Children) programme.
New hospital plans identified a 75% single-room occupancy per ward with pull-out beds for families. The plans showed designated lounge areas for young people within ward settings.
Young people’s groups had been actively involved in decision making on the future of the trust. Examples of these were the Children and Young People’s Forum, medicines group and new hospital build group.
As part of the new tender process, young people were invited to influence the decision of the final choice of hospital design.
We found excellent examples of evidence that young people were involved in the new build, which included choice of fabric and furnishings and challenging the choice of IT services.
The trust had a wide range of activities aimed at young people – for example, music, performing arts, and photography.
We identified that there was no trust lead to support young people with learning disabilities. We spoke with staff that were unclear on who coordinated services for young people with learning disabilities.
Young patient experience data was collected at the trust and reported to the board. This information demonstrated that children and young were happy with how they were treated by staff and included in decision making about their care. They also reported that they were less happy with information they received when they were discharged from hospital
The trust has set itself a target of 90% compliance with all mandatory training. This has not been met in any identified mandatory training area. The highest rate of completion was fraud, complaints, infection control (non-clinical), health & safety and manual handling – all of which were 80% or above. Compliance below 80% was: fire – 70%; equality & diversity – 62%; information governance – 58%; infection control (non-clinical, clinical areas) – 69%; infection control (clinical) – 79%; resuscitation – 41%; practical manual handling – 30%; major incidents – 66%; conflict resolution – 41%; medicines management – 43%; transfusion e-learning – 69%.
Work to increase the levels of mandatory training should be a priority for the trust so that it can be assured that staff maintain their competency in these key areas.
We also found
- National guidelines were used to treat children and young people and care pathways reflected national guidelines. Standards were monitored and outcomes were good when compared with other children’s hospitals.
- The trust had a well-established mortality review process.
- In the surgical service, the recovery rates for children and young people were favourable when compared to similar hospitals.
- In the medical wards, care was planned and delivered in a way that took children and young people’s wishes into account.
- Access to advice and information was good for children and young people, their families and carers, both during the hospital stay and after discharge.
- Some children and young people were concerned that they had to wait for long periods of time in the A&E department and did not always realise that they had been admitted to the observation unit.
- In the paediatric intensive care unit there was evidence of strong medical and nursing leadership.
- Strong professional nurse leadership on the HDU.
- The specialist palliative care team provided a safe, effective and responsive service to children and young people with life-limiting illness. Children and young people were appropriately referred and assessed by the specialist palliative care team.
- A bereavement service supported families’ emotional needs at the end of life and afterwards.
- Counselling support was available through the Alder Centre.
- In transitional services, we found examples of excellent pathways for young people transitioning to adult services with specific long-term health needs. However, we found that there was no overall responsibility or leadership for transitional services within the trust.
- In the outpatients department, there were concerns regarding long waiting times and the availability of case notes and records.
We saw several areas of good practice, including:
- The medical division participated in research at local, national and international levels. The trust is the first Investing in Children accredited hospital in the UK.
- Alder Hey Children’s Hospital has a gait laboratory to assess walking for children with neuromuscular disorders, such as cerebral palsy, which is not available elsewhere in North West England. The service therefore receives referrals from all over the North West.
- Trust physiotherapists have linked with the community physiotherapists to provide appropriate postoperative care and a trust audit demonstrated that this has translated into improved outcomes for children and young people.
- The surgical department received a significant research grant to coordinate a national trial aimed at reducing the rate of infection following shunt operations for children with hydrocephalus (build-up of fluid on the brain). The results of this project will be used to produce good practice guidance to improve the care and treatment for children nationally and internationally.
- When babies were admitted to the NSU, parents were taught correct hand-washing techniques. The unit was developing infection control safety cards for parents.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Continue to address staffing shortfalls. Nurse staffing levels must also be appropriate in all areas, without substantive staff feeling obligated to work excessive hours or additional shifts.
- Provide a longer-term solution for the medical leadership on the HDU.
- Ensure that children and young people who require one-to-one support in the isolation pods on the HDU receive it.
- Take action to ensure there are sufficient levels of nursing staff across the HDU.
- Continue to take action to ensure that clinical records are available in the outpatients department.
- Take action to ensure that nurses are following the trust’s policy regarding the safe administration of medicines.
- Review the resuscitation equipment on each surgical ward to ensure that this meets the minimum equipment and drugs required for paediatric cardio-pulmonary resuscitation as outlined in the Resuscitation Council (UK) 2013 guidance.
- Address the shortfalls in governance and risk management systems.
- Improve the timely completion of investigation of incidents and Never Events (serious harm that is largely preventable) so that learning can be systematically applied to avoid recurrence.
In addition the trust should:
- Review its pharmacy arrangements to improve support to wards out of hours and at weekends.
- Ensure that the A&E department clarifies its use of the observation ward as a CDU and make it clear to children and young people and their parents when they have been transferred to the CDU rather than being in A&E.
- Ensure that the A&E department reviews its arrangements for providing food and drinks in the waiting areas, and make it clear that hot and cold drinks and food are available on request.
- Ensure that children, young people and their parents using A&E services are aware of the trust’s complaints procedure and are supported in using it where necessary.
- Review the provision of isolation cubicles within the hospital to isolate children and young people who may represent an infection risk to others.
- Consider changing open storage units to closed ones in the surgical wards to reduce the risk of cross-infection, especially in areas where clinical procedures take place, such as the treatment rooms.
- Consider removing the bin in the children’s play area on Ward K3.
- Consider reviewing the risk assessment for the fire escapes in the surgical wards to make sure they are secure enough to prevent children and young people leaving unnoticed and protect against people entering unobserved.
- Consider the provision of a dedicated health play specialist and psychology resource to the critical care areas.
- Ensure that the arrangements stated in the board papers received by the inspection chair on 22 May 2014 concerning the medical cover in HDU are monitored.
- Ensure that staff report incidents on the NSU.
- Ensure that staff effectively check and sign resuscitation equipment on the NSU.
- Ensure that drug charts are appropriately completed on the NSU.
- Review the learning disability service provision to ascertain roles and responsibilities of both nurses and doctors for adolescents and young people in transition.
- Consider the Trust’s overall strategy, board reporting mechanisms and leadership responsibilities related to transitional care.
- Take action to implement risk assessments in the outpatients department. The risk assessments would ensure the safety of children, young people, relatives and staff within the department.
- Ensure staff in the outpatients department have the opportunity to receive clinical supervision via a Trust wide model.
- Improve systems to ensure children and young people and their relatives and carers can make appointments in the outpatients department.
- Ensure letters sent to children and young people and their parents and carers are in the appropriate community language for those people who do not speak English as a first language.
- Ensure that staff in the outpatients department are effectively engaged in the development of the service.
- Improve staff engagement across all services and improve the visibility of the board and senior team.
- Improve the communication with staff to demonstrate a listening and responsive senior team.
Professor Sir Mike Richards
Chief Inspector of Hospitals